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Objective: To construct normal ranges for umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI) and cerebroplacental ratio (CPR) in prolonged pregnancies according to strict methodological criteria using polynomial regression analysis., Methods: This was a retrospective, cross-sectional observational study involving 140 women, 10 women for each gestational day between 287 and 300 days of gestation. Fetal Doppler parameters were assessed to construct normal reference ranges for UA PI and MCA PI. CPR was calculated as a ratio of MCA PI/UA PI., Results: Mathematical modeling of the data demonstrated that the optimal fit was a linear polynomial one. Mean, 5th and 95th centiles were calculated for UA, MCA and CPR and centile curves from the regression analysis were constructed., Conclusions: Reference ranges for UA PI, MCA PI and CPR in prolonged pregnancies have been constructed. MCA PI shows a wider range than previously reported in the literature.

Objective: Skewed gender distribution and falsely assigned gestational age lead to unnecessary or late obstetric intervention in prolonged pregnancy. The aim of this study was to examine the consequences of a fetal gender-dependent systematic 1.5-day dating error at ultrasound fetometry., Material and Methods: A total of 82 484 singleton deliveries >/=37 weeks at 11 hospitals in southern Sweden from 1995 to 2000 were included. Frequencies of labor induction and Apgar scores <7 at 5 min were compared with regard to fetal gender, both before and after correction of gestational age by adding 0.75 days to female-fetus pregnancies and subtracting 0.75 days from male-fetus pregnancies., Results: The uncorrected odds ratio for having a male baby at >/=42 weeks was 1.41 (95% confidence interval, 1.33-1.49). After adjusting gestational age by +/-0.75 days, the odds ratio reduced to 0.90 (95% confidence interval, 0.84-0.95). The risk for labor induction was significantly above unity in male-fetus pregnancies delivered after 41 weeks when gestational age was corrected for fetal gender, while the risk for female fetuses having a low Apgar score was not significantly increased compared to male fetuses (P = 0.087)., Conclusion: Skewed gender distribution in prolonged pregnancy results in a higher rate of labor induction in pregnancies with male fetuses at >/=41 weeks, and the risk for newborn females having a low Apgar score in prolonged pregnancy is not significantly increased compared to boys., (Copyright 2003 ISUOG. Published by John Wiley & Sons, Ltd.)

Objective: To study the cesarean rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix., Study Design: A total of 249 women with uncomplicated pregnancies at 41 weeks plus 3 days (290 days) with favorable cervix (Bishop score > or =6) were randomized to either expectant management (n=125) or immediate induction of labor (n=124). The women in the induction group were sent to labor ward for induction by artificial rupture of membranes (ARM) and/or oxytocin infusion. The women with expectant management had nonstress test (NST) and amniotic fluid index (AFI) performed once a week and twice a week after 43 weeks of gestation until spontaneous labor., Results: The cesarean rate was not different between expectant management and immediate induction (21.6% versus 26.6%; P=0.36). Ninety-five percent of the expectant group delivered within 1 week after enrollment, and all of them delivered within 9 days after randomization. Maternal and fetal complications in both groups were not different. There was also no difference in the mean birth weight (P=0.24) and the frequency of macrosomia (birth weight > or = 4000 g) between the two groups (P=0.23)., Conclusion: Cesarean section rate between expectant management and immediate induction in the otherwise uncomplicated postterm pregnancy with favorable cervix was not different. Due to the very low adverse perinatal outcome, both expectant management and immediate induction are acceptable.

Objective: Our purpose was to examine changes in the amniotic fluid index (AFI) in accurately dated term pregnancies both in relation to gestational age and in relation to the onset of spontaneous labor., Study Design: This was a prospective observational study in 137 women with uneventful term pregnancies, in whom 220 AFI measurements were performed. More than one AFI value was available from 51 individuals., Results: The AFI did not change significantly between 37 and 42 weeks' gestation, but a significant reduction was seen during the last 11 days before the spontaneous onset of labor (R = -0.37, n = 83, p < 0.001). The AFI (corrected for gestational age) within individuals remained stable over periods of up to 2 weeks. Meconium staining of the amniotic fluid was related to gestational age, but not to the AFI or fetal distress at birth. No significant correlation was found between fetal distress and the AFI, or between fetal distress and the reduction in AFI during the last two measurements before labor., Conclusions: The reduction of the AFI in pregnancies progressing beyond term is related to the labor process itself rather than to the exact gestational age.

Objective: To study the relationship between induced labour, quantitative levels of fibronectin and the Bishop score., Study Design: Vaginal fibronectin/Bishop score were estimated in 33 nulliparous women undergoing induction of labour for post-dates at the Department of Obstetrics and Gynaecology, Guy's and St. Thomas' Hospital London., Results: There was no significant relationship between either the fibronectin level or Bishop score and the duration of the latent phase (R(2)=0.001; P=0.86 and R(2)=0.12; P=0.08, respectively). There was no relationship between the total prostaglandin dose and fibronectin level (R(2)=0.03; P=0.39) nor any significant correlation between either the Bishop score or fibronectin level and the induction to delivery time (R(2)=0.13; P=0.11 and R(2)=0.0006; P=0.97, respectively). Significant relationships were observed inversely between the total prostin dose and Bishop score (R(2)=0.33; P=0.002), between the total prostin dose and latent phase (R(2)=0.54; P=0.000009) and between Bishop score and the fibronectin levels (R(2)=0.19; P<0.01)., Conclusions: Quantitative foetal fibronectin is not a useful test for inducibility at term.

Our purpose was to determine whether the Doppler cerebroplacental ratios predicts perinatal outcome in postterm pregnancy. The middle cerebral to umbilical artery resistant and pulsatility indices (MCA PI/UA PI and MCA RI/UA RI) were measured in 59 postterm pregnancies. We found significant correlation between MCA PI/UA PI, MCA RI/UA RI, nonstress testing and intrapartum fetal heart rate assessment. There was also an association between MCA PI/UA PI and 1- and 5-minute Apgar score. We conclude that the Doppler cerebroplacental ratios provide useful information about perinatal outcome.

Unlabelled: It was a retrospective and continuous prospective study about 102 post-term pregnancy recensed on a 14 months period. The aim of this study is to evaluate our management of post term pregnancy and the peto-maternal morbidity and mortality., Results: Frequency of post-term pregnancy in our study is 5.92%, in rate of session sector is not higher it is of 18.62. There is no maternal mortality. Neonatal mortality is a about 19/1000, the rate of neonatal morbidity is 2.9%.

This paper evaluated how the pregnancy after 41 completed weeks' gestation with amniotic fluid index (AFI) > 6 has a slower response to the prostaglandin E2 (PGE2) induction. Eighty-one post-term pregnancies (41 completed gestations' weeks) with unfavorable cervix were considered in this follow-up. Induction was performed by means of intracervical PGE2 gel (Dinoprostone 0.5 mg). After 12 hours, if the cervix was still unfavorable, then another gel administration followed. Cases that had oxytocin administration were excluded from the study. The median time of spontaneous delivery in the overall series was 25 hours, 14 minutes. We had 18 cases of cesarean section (22.2%). In the group of pregnancies with AFI > 6 (60 cases) and in the group with AFI < or =6 (21 cases), the median time of spontaneous delivery was 29 hours, 25 minutes and 23 hours, 39 minutes, respectively (p-value = 0.02). The rate of cesarean sections was 26.67 and 9.52, respectively in the two groups (p-value >0.05). Two out of four cases of cesarean sections for fetal distress belonged to the group of AFI > 6. All the 14 cases of cesarean section for dystocia belonged to the group with AFI > 6. Considering just patients who did not deliver within 12 hours (57 cases), median time of spontaneous delivery was 33 hours and 24 hours 40 minutes for group AFI > 6 (42 cases) and AFI < or =6 (15 cases), respectively (p-value = 0.0009). Thirty-one cases out of 57 had another PGE2 gel administration. Adjusted odds ratio was 0.33 (0.16-0.65, 95% C.I.) for AFI < or =6 versus AFI > 6.

Objective: Recent studies have documented increased perinatal morbidity and mortality rates in the growth-restricted postterm fetus. Our purpose was to evaluate the receiver operating characteristic curve of ultrasonographically estimated fetal weight as a predictor of fetal growth restriction in prolonged pregnancies., Study Design: Fetal weight was estimated ultrasonographically within 9 days of delivery (mode 1 day) in members of a cohort of 410 patients with prolonged pregnancies (>41 weeks). Estimated fetal weights were compared with birth weights in receiver operating characteristic curve analysis., Results: The areas under the receiver operating characteristic curves for predicting birth weights <10th percentile (3125 g in this population) and <5th percentile (2930 g in this population) were 0.89 and 0.96, respectively. Both areas were significantly different from an area indicating a useless test. The estimated fetal weight values corresponding to the inflection points for the receiver operating characteristic curves predicting birth weights <10th percentile and <5th percentile were 3370 and 3200 g, respectively. With estimated fetal weight at less than these test cutoff values, the relative risks for a fetus to have a birth weight <10th percentile or <5th percentile were 14.6 (95% confidence interval, 6.25-33.8) and 89.8 (95% confidence interval, 12.1-665), respectively. Analysis of the receiver operating characteristic curves resulted in improved test characteristics relative to using the actual 10th and 5th birth weight percentiles as cutoff values for estimated fetal weight (relative risk of 14.6 vs 9.5 and 89.8 vs 26.0, respectively)., Conclusions: Ultrasonographic estimation of fetal weight is a useful test for predicting fetal growth restriction in prolonged pregnancies. Future studies should evaluate whether intervention on the basis of this identification results in improved perinatal outcome.

Objective: To determine whether fetal erythropoietin (Epo) concentrations are increased in pregnancies extending beyond 41 weeks' gestation and whether this is influenced by the presence of meconium-stained amniotic fluid., Methods: Epo concentrations were measured in 116 fetal umbilical cord blood samples from otherwise uncomplicated pregnancies between 37 to 43 weeks' gestation during the period of October 1996 to October 1997. An enzyme-linked immunosorbent assay kit was used to measure Epo. Maternal demographics and birth outcomes including Apgar score, cord blood pH, and base deficit were obtained. Fetuses born between 41 and 43 weeks' gestation (post-term) were compared with matched controls born between 37 and 40 weeks' gestation (term). In addition, both post-term and term fetuses with meconium-stained amniotic fluid were compared with matched controls without meconium., Results: Post-term fetuses without meconium had significantly higher Epo levels compared with term fetuses (mean +/- SEM: 50.6 +/- 6.5 versus 29.5 +/- 3.3 mIU/ml, p = 0.002). When matched for gestational age, fetuses with meconium-stained amniotic fluid had significantly greater Epo concentrations compared with controls without meconium (post-term, 80.7 versus 50.6 mIU/ml; term, 61.4 versus 29.5 mIU/ml; p < 0.05). However, no significant difference in Epo levels was found between post-term fetuses with meconium and term fetuses with meconium (80.7 +/- 15.7 mIU/ml versus 61.4 +/- 12.8 mIU/ml, respectively). Mean cord blood pH and base deficit values for all groups were within normal clinical range., Conclusion: Cord blood Epo concentrations were significantly increased in pregnancies extending beyond 41 weeks. Irrespective of gestational age, meconium-stained amniotic fluid was associated with a significant rise in Epo. High Epo levels in these pregnancies imply subacute or chronic fetal hypoxia. Close clinical monitoring of post-term fetuses and those with meconium-stained amniotic fluid is warranted.

A decrease in amniotic fluid in prolonged pregnancy is associated with increased fetal morbidity. However, few investigations have been reported on the prediction of this condition. Fetal renal arterial pulsatility index (PI), hourly fetal urine production rate (HFUPR) and amniotic fluid index (AFI) at 39 weeks were studied in 51 singleton pregnancies with (n = 14) and without oligohydramnios (AFI < 5, n = 37) in prolonged pregnancy. There was no difference in the average fetal renal arterial PI and HFUPR between the oligohydramnios group and the normal group. However, the average AFI in the oligohydramnios group was 7.5 +/- 0.9, which was lower than that in the normal group (p < 0.05). We speculated that AFI value at 39 weeks is useful for predicting the incidence of oligohydramnios in prolonged pregnancy.

Objectives: Case of advanced ovarian pregnancy are exceptional because ovarian pregnancy itself is very rare., Study Design: The authors describe a case of prolonged ovarian pregnancy with retention of the dead fetus for more than a year. Usually ovarian pregnancy finishes in rupture which occurs before the end of the first trimester. It is then difficult to make out the integrity of the organs and in particular of the tube and indeed to recognize them. On the other hand when the mass persists intact with the development of pregnancy in a retort shape, it is easy to see how confusion is possible and arises between it and an intra-uterine pregnancy. In this case, however, the different anatomical forms are clear and an almost definite diagnosis can be made at the time of operation (the three first criteria of Spiegelberg). The diagnosis of ovarian pregnancy is never made before operation. At the very best one can say, when things happen early, that an extra-uterine pregnancy has ruptured, or in certain particular circumstances like in the case we are reporting lithopedian. The presence of ovarian tissue in the wall of the sac, which is the fourth criterion of Siegelberg, is easier to recognize in early accidents than in advanced cases of ovarian pregnancy in which the parenchyma of the ovary is compressed, distended and laminated by the increasing development of the fetus and the adnexae. The absence of the placenta being adherent to other organs than the ovary can then be kept as a worthwhile criterion of ovarian pregnancy.

Objective: Our purpose was to determine the optimal management of pregnancies beyond 41 weeks' gestation with a cervix unfavorable for induction., Study Design: All uncomplicated pregnancies that reached 41 weeks' gestation with a Bishop score of < or = 4 were randomly assigned to one of three groups: (1) daily cervical examinations, (2) daily membrane stripping, or (3) daily placement of prostaglandin gel until 42 weeks., Results: In 105 pregnancies the Bishop score on admission to labor and delivery was significantly greater in the groups receiving prostaglandin or stripping of the membranes versus the control group, whereas the converse was time of gestational age at delivery (p = 0.0001). Fewer patients required induction in the two treatment groups (20%, 17%) versus the control (69%) patients (p < 0.0001)., Conclusions: Daily membrane stripping or daily placement of prostaglandin gel is successful in reducing the number of inductions at 42 weeks for postdatism.

Objective: To investigate the association between fetal, umbilical and uterine circulatory changes and adverse perinatal findings in very prolonged pregnancies., Study Design: 44 women proceeding to 43 completed weeks of gestation with the intention of a trial of vaginal delivery were studied prospectively with ultrasound Doppler velocimetry. An intensified fetal surveillance was routinely commenced at 42 weeks and only uncomplicated pregnancies were allowed to proceed. The endpoint perinatal measures were oligohydramnios, fetal meconium release, fetal distress in labor and birth asphyxia. Flow variables in different groups were compared with the Mann-Whitney U test, Student's unpaired t-test, Wilcoxon signed-rank matched-pairs test, Fisher's exact test and contingency table analysis, and a two-tailed P value <0.05 was considered statistically significant., Results: The umbilical artery pulsatility index was significantly lower in cases of fetal meconium release (n=12) and fetal distress (n=7). The umbilical venous flow velocity was significantly lower in cases of meconium, and the fetal aortic volume flow significantly higher in cases of fetal distress. No significant flow changes were found in connection with oligohydramnios (n=5) and birth asphyxia (n=2). Uterine flow was not significantly affected in any group., Conclusions: In very prolonged pregnancies, fetal distress in labor was not associated with an increased placental vascular resistance. In contrast to previous reports, the umbilical artery pulsatility index was low in cases of fetal distress and meconium release. The etiology is unknown, but a subclinical fetal hypoxia might have triggered a vasodilation of placental vessels. Vasodilation at an unchanged volume flow could also explain the decrease of umbilical venous flow velocity. The increased aortic volume flow indicates an increase of cardiac output in fetuses later developing distress in labor.

Postmature infants calm less when presented with sucrose solutions than term infants. To further assess the influence of postmaturity on sucrose responsivity, several motoric responses were examined in healthy term neonates and chronically stressed postmature (> or = 288 days gestational age (GA) e.g., > 41 weeks) neonates with Clifford's Syndrome tested between 5-91 h of age. Following baseline observations, each subject was presented with 0.1 ml of a 14% sucrose solution for 10 s each min for 5 min, and observations were continued for 5 min following stimulation. During sucrose stimulation and poststimulation phases, postmature infants showed more tremors during quiet state than term infants. Across conditions, postmature infants exhibited increased finger sucking, rhythmic sucking, but less mouth opening and arm movements than healthy, term infants. Sequence analysis revealed that short-latency mouthing, repetitive movements of the upper and lower lips, followed sucrose infusion reliably in postmature infants, but not term infants. These results suggest that postmaturity is associated with: 1. Increased oral behaviors associated with arousal and self soothing; and 2. Increased sucrose reactivity, as indicated by contingent mouthing and increased tremors.

Objective: Our purpose was to determine whether postterm patients with oligohydramnios differ in their fetal and umbilical blood flow distribution from those with a normal volume of amniotic fluid., Study Design: Pulsed-wave Doppler imaging was used prospectively to determine the resistance index in the fetal middle cerebral, renal, and umbilical arteries in 57 postterm (i.e., > 41 weeks' gestation) pregnancies. Semiquantitative assessment of amniotic fluid volume was obtained by use of the ultrasonographically determined amniotic fluid index., Results: Oligohydramnios (amniotic fluid index < 5 cm) was detected in 15 patients; 42 patients with a normal amniotic fluid index served as a control group. The various resistance index values and the ratio s among them were not significantly different when patients with oligohydramnios were compared with controls (0.51 +/- 0.1 vs 0.52 +/- 0.06, 0.63 +/- 0.1 vs 0.64 +/- 0.08, and 0.71 +/- 0.08 vs 0.73 +/- 0.05 for the umbilical, middle cerebral, and renal arteries, respectively). However, the mean birth weight (in grams) was significantly lower (3297 +/- 438 vs 3742 +/- 448, p < 0.003), in the oligohydramnios group., Conclusion: Oligohydramnios was not associated with a major redistribution of blood flow in postterm patients, suggesting that the cause of oligohydramnios in these patients is related to birth weight rather than to renal perfusion.

A total of 153 pregnant women, of at least 287 days' menstrual age, were studied in a prospectively designed cross-sectional trial. In addition to the non-stress test, contraction stress test, sonographic estimate of amniotic fluid and grade of placental maturation, Doppler measurements of the resistance index (RI) were taken in the umbilical artery, the uteroplacental arteries in the region of placental implantation and the fetal middle cerebral artery. Data were analyzed with regard to asphyxia and otherwise complicated fetal outcome. Furthermore, a possible relationship between grade of placental maturation, Doppler flow velocity waveforms and fetal outcome was investigated. Doppler resistance indices in the umbilical artery, uteroplacental arteries in the region of placental implantation and fetal middle cerebral artery did not change significantly with increasing gestation from 41 to 43 weeks. The grade of placental maturation on ultrasound examination was not related to fetal outcome or Doppler indices in the first two vessels. In all vessels examined in this study, the majority of Doppler measurements in pregnancies with subsequent asphyxia or otherwise complicated fetal outcome were within the 95% prediction interval for patients with normal fetal outcome. None of the patients showed absent diastolic flow in the umbilical artery. With the use of a cut-off value of RI = 0.62 in the umbilical artery, asphyxia could be predicted with 37% sensitivity and 75% specificity. Oligohydramnios and antpartum cardiotocography predicted asphyxia with 16% and 8% sensitivity and 95% and 96% specificity, respectively. Sensitivity for prediction of otherwise complicated fetal outcome by umbilical artery Doppler was only 7%.(ABSTRACT TRUNCATED AT 250 WORDS)

There have been various estimations of the frequency of postdate pregnancies. On the average, 10% of all pregnancies exceed 42 weeks amenorrhoea with a range from 4 to 14% according to the authors. Rates vary with use of ultrasound examinations early, avoiding false dating and induced labour. A pregnancy becomes a pregnancy at risk at the end of the 41st week of amenorrhoea. Fetal maturity may be affected by a disease process or due to individual or ethnic variations. The potential danger of prolonged pregnancy is inhalation of meconium prepartum. Expulsion of meconium is both a frequent consequence of fetal distress and the result of increased intestinal reactivity. There does not appear to be agreement on the degree of risk of sudden death at the end of pregnancy, although the risk does appear to exist. Surveillance should include recording fetal heart rate under basal conditions and an assessment of the amniotic fluid volume with ultrasounds. The Doppler technique is currently under study. When the status of the cervix is favourable, labour may be induced by rupturing the membranes of with a perfusion of Syntocinon. When the status of the cervix is unfavourable, prostaglandin E2 is applied intravaginally or intracervically with a gel. Therapeutic trial published to date do not demonstrate any advantage over cesarean section or fetal morbidity. The safety of the procedure has not been proven. Randomized trials comparing systematic induction of labour with a wait-and-see attitude have not given a definitive answer. Only two trial have shown a significant advantage of systematic induction of labour. The others have shown that the rate of cesarean section and neonatal morbidity are comparable in the two groups.

Newborn foals of mares grazing on Acremonium coenophialum-infected fescue pasture throughout gestation or from gestation day 300 to parturition had increased gestation duration and decreased serum triiodothyronine concentration. Pregnant mares were allotted to 4 treatments: grazing continuously on endophyte-free (E-) fescue, grazing continuously on endophyte-infected (E+) fescue, grazing on E+ fescue from gestation day 300 to parturition, and grazing on E+ fescue from conception to gestation day 300. Morphometric studies indicated that foals born to mares exposed to endophyte late in gestation had large, distended thyroid follicles lined by flat cuboidal epithelial cells. Mean triiodothyronine concentration in foals exposed to endophyte (395.2 ng/dl) was decreased (P < 0.01), compared with mean values in control foals (778.0 ng/dl). Thyroxine and reverse triiodothyronine concentrations were not significantly different among groups. Foal organ weight as a percentage of foal body weight was not significantly different among experimental groups.

Objective: Our purpose was to study the association between dynamic changes in serial amniotic fluid index measurements and adverse fetal outcome in postterm pregnancies., Study Design: Serial amniotic fluid index values were obtained semiweekly in 139 reliably dated, uncomplicated, singleton pregnancies at > 41 weeks' gestation. Adverse fetal outcome was defined by the presence of moderate or thick meconium, fetal heart rate decelerations, cesarean delivery for fetal distress, neonatal intensive care unit admission, and perinatal mortality., Results: Prominent changes in the amniotic fluid index (i.e., > 50% increase or decrease) had no association with adverse fetal outcome irrespective of rate of change, provided the final value remained > 5.0 cm. A significant association with fetal heart rate decelerations and the presence of meconium was detected only in patients whose final amniotic fluid index was < or = 5.0 cm (p = 0.007 and p = 0.003, respectively)., Conclusion: Irrespective of the rate of change in amniotic fluid index, postterm pregnancies are significantly associated with potential complications such as fetal heart rate decelerations and meconium staining when the final amniotic fluid index is < or = 5.0 cm.

The causes of prolonged pregnancy are still largely unknown and their investigation requires a detailed observation of potential birth-initiating stimuli on the endocrine and biomolecular level. A large number of clinical and biochemical studies point to the central importance of prostaglandins for the beginning of human birth. The main places of origin of the intensified prostaglandin formation and release are the amnion and the decidua which has "macrophage-like" properties and functions. The superordinate regulation and trigger mechanisms for intensified uterine prostaglandin production has not been sufficiently investigated either. Possible factors currently being debated include local changes in estrogen and progesterone biosynthesis in fetal membranes and decidua, subclinical inflammatory reactions with the activation of macrophages and the consecutive release of cytokines, and a loss of maternal immune tolerance with a time-determined rejection reaction. In addition, the substances inhibiting and stimulating prostaglandin synthesis have been detected in the amniotic fluid, fetal membranes and decidua. The fetus itself also plays an important part in the initiation of labor. Prolongation may be due to anatomic functional disturbances of the one hand which prevent the activation of the fetal hypothalamic-hypophyseal-adrenal axis and the release of the birth-initiating stimuli originating in the fetus; on the other hand, an elevated immune tolerance with a delayed rejection reaction or the lack of "bacterial stimulus" may inhibit the activation of the macrophages and hence the formation of cytokines. The consequences would be the development and release of a quantity of prostaglandins from the fetal membranes and decidua insufficient to overcome the pregnancy-maintaining safety systems.(ABSTRACT TRUNCATED AT 250 WORDS)

Perinatal mortality is increased in pregnancies over 42 weeks, but can be reduced by the induction of labour. However, clinicians must consult with the patient as to whether she would rather experience spontaneous onset of labour or accept this increased risk. This article weighs up the important considerations in this difficult area.

Objective: To study the role of Doppler ultrasound examination in predicting an abnormal perinatal outcome, among post-term pregnancies uncomplicated by an abnormal non-stress test (NST) or reduced amount of amniotic fluid., Design: A prospective study., Setting: High-risk pregnancy unit, Hadassah Mt. Scopus University Hospital, Jerusalem., Subjects: Seventy-eight women with confirmed gestational age of > 287 days, who had normal initial evaluation and unfavourable cervical examination., Interventions: Doppler flow velocity waveforms were recorded from the umbilical and middle cerebral arteries, and from the descending thoracic aorta., Main Outcome Measures: Correlation between Doppler measurements and data regarding delivery., Results: Women who developed signs of fetal distress during labour, or who required intervention because of fetal distress, had elevated umbilical artery systolic/diastolic ratio, decreased middle cerebral artery pulsatility index, and decreased time average aortic blood flow velocity. Umbilical artery Doppler measurements could significantly predict the need for intervention due to fetal distress., Conclusions: Doppler examination of uncomplicated post-term pregnancies may identify patients with normal results as having a low risk of developing fetal distress during labour. Patients with abnormal Doppler results are prone to need intervention following fetal distress in labour.

Doppler sonography can help to assess a foetal risk situation prospectively. This procedure is therefore well suited for the screening of risk pregnancies in the 3rd trimenon. The role of Doppler ultrasound at delivery is still controversial, since, on the one hand, no data on the behaviour of Doppler parameters directly at the onset of delivery are available, and on the other hand the obstetric consequences from pathological findings are not clear. For this reason, we observed 45 normal pregnancies from the 10th day prior to the date of confinement till the 10th day post partum. In 20 patients we registered Doppler parameters from 4 days before until the onset of true labour. In all these cases, a reduction of the end-diastolic blood flow in the foetal aorta was found, which became evident by the increase of the resistance index to pathological values. Concomitant decrease of the resistance index in the foetal carotid artery was typical for a circulatory system. Since foetal outcome was normal in all newborn, this change in Doppler parameters directly at the beginning of labour must be considered as physiological. The findings suggest a physiological placental insufficiency. Since however, parameters in the uterine vessels did not show any changes, the insufficiency has its probable origin in the placenta. From these findings, one might speculate, that the supply deficiency is the labour inducing factor. No clinical consequence can thus result from pathological Doppler data found in patients directly prior and after delivery. Cardiotocographic screening is necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: Our purpose was to determine Doppler waveforms of the fetal human renal artery in prolonged pregnancy in the presence or absence of oligohydramnios., Study Design: Fifty patients at or after 40 weeks were studied. Ultrasonography was performed to determine the amniotic fluid index by the four-quadrants technique. Two groups of patients were obtained on the basis of the amniotic fluid index. Group 1 had an amniotic fluid index > 5 (normal) (n = 33); group 2 had amniotic fluid index < or = 5 (oligohydramnios) (n = 17). Umbilical artery and fetal renal pulsed Doppler waveforms were determined and analyzed. The fetal renal artery systolic-to-diastolic ratio of the two groups was compared., Results: Fetuses with a low amniotic fluid index had a significantly higher ratio. A significant negative correlation coefficient between amniotic fluid index and fetal renal systolic/diastolic ratio was found (r = -0.435 and p < 0.01)., Conclusions: In prolonged pregnancies there is a significant relationship between the amniotic fluid index and the fetal renal systolic/diastolic ratio. In pregnancies associated with oligohydramnios the systolic/diastolic ratio is significantly higher than in those with normal amniotic fluid volume. These data suggest that intrarenal flow in prolonged pregnancies complicated with oligohydramnios is significantly different.

The capability of Doppler flow velocimetry to predict intrauterine growth retardation is well known. The increased morbidity and mortality rate of postterm newborns is also well known. The aim of our study was to examine if Doppler flow velocimetry is able to indicate foetal jeopardy in the postterm period. Flow velocimetry of the foetal descending aorta, the umbilical artery, the uterine arteries and in 59 cases also the foetal middle cerebral artery was obtained from 167 pregnancies after 40 completed weeks of gestation. We found significant changes of normal values in prolonged pregnancy compared to third trimester normal values, examining the mean velocity of the foetal descending aorta and the S/D-ratio of the umbilical artery. No clinically significant changes were found examining the S/D-ratio of the uterine arteries and the pulsatility index of the foetal middle cerebral artery. Daily examinations of the foetal descending aorta were carried out in 23 and of the umbilical artery in 19 cases during the last four days before delivery, and in 11 cases of the foetal middle cerebral artery during the last three days before delivery. We did not find significant changes in the medians of the mean velocity of the foetal aorta, of the S/D-ratio of the umbilical artery and of the pulsatility index of the foetal middle cerebral artery. Measurement of sensitivity and positive predictive value of the four arteries examined showed, that Doppler ultrasound could not predict small for date infants or Caesarean section because of foetal distress.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: To determine the amniotic fluid (AF) volume estimation technique with the greatest diagnostic value with respect to perinatal outcome in the postdate pregnancy., Methods: One hundred ninety-eight women who were at least 40 weeks' gestation based on ultrasound confirmation or establishment of dates were evaluated twice weekly with nonstress tests (NSTs) and AF volume estimation. Various indices of AF volume were measured and correlated with perinatal outcome. Receiver operating characteristic curves were used to determine optimal cutoff values., Results: There was a significantly larger maximal vertical pocket in those pregnancies with a normal perinatal outcome than in those with abnormal outcome (4.2 +/- 1.4 versus 3.2 +/- 2.0 cm; P = .02). A statistically significant difference was also seen with the AF index (10.0 +/- 4.5 versus 7.5 +/- 5.0 cm; P = .01). Analysis revealed that the optimal cutoff for identifying clinically significant oligohydramnios was a largest vertical pocket less than 2.7 cm, with an adjusted odds ratio for abnormal perinatal outcome of 7.11 (95% confidence interval [CI] 2.79-18.16). Its sensitivity of 50.0% and specificity of 87.9% were superior to the diagnostic value of the AF index of 5 cm, which had a sensitivity of 29.2% and specificity of 89.1%., Conclusion: A largest vertical pocket threshold of 2.7 cm had the greatest diagnostic value for identifying the postdate pregnancy at risk for abnormal perinatal outcome, surpassing the AF index and the 2-cm largest vertical pocket rule.

One hundred forty-two gravid women at term were followed prospectively by a non-stress test, estimation of amniotic fluid volume and Doppler velocimetry of the umbilical and uterine arteries. Adverse perinatal outcome was detected in 12 women (8.5%). Abnormal antepartum tests were detected in 26 women (17%). Seven women had an abnormally elevated resistance index (RI) in the umbilical artery; but only two had an abnormal outcome. Seven women had an abnormally elevated RI in the uterine artery, but only two had abnormal outcome. Three out of 11 women with oligohydramnion had abnormal perinatal outcome. Only one out of seven women with an abnormal non-stress test had abnormal perinatal outcome. In six women, more than one antepartum test was abnormal. The various surveillance methods demonstrated a low sensitivity (the highest was obtained by estimating amniotic fluid volume: 25%) and a low positive predictive value (the highest obtained by measuring the resistance index in either the umbilical or the uterine arteries: 28.6%). By considering any abnormal test as a positive test result for a given patient, a substantial improvement in sensitivity (66.7%) and positive predictive value (33.3%) are obtained. Doppler velocimetry adds very little in itself to the follow-up of patients with post-term gestations. However, when combined with additional antepartum tests, it may increase our ability to predict the compromised fetus in this condition.

The intrapartum FHR and UC were recorded in a population of 707 consecutive cases of prolonged gestation looking for a characteristic pattern. There is no typical pattern for prolonged pregnancy. However, there are differences from preterm and term populations. There is a very high incidence of variable (55%) and late (17%) decelerations. These were seen more frequently among cases receiving oxytocin. Nearly 50% of C-sections had lates. Baseline alterations (tachycardia 26%, fixed 8%, and saltatory 17%) were often associated. Apgar scores < or = 6 at 1 minute were correlated with variable and late decelerations. However, acidemia (UA pH < or = 7.20) could not be predicted from FHR patterns because there was no correlation between low pH and clinical depression. Alarmingly a few fetuses in agonal state presented normal appearing tracings, or deteriorated rapidly without the usual indicative changes by FHR. All intrapartum or NND had this misleading pattern. In view of this unpredictable aberrant pattern as the only certain means to prevent these deaths, it is suggested that no pregnancy should be allowed to reach 294 days post LMP.

Ultrasound examination has become an indispensable tool in antenatal care. In cases with intrauterine growth retardation, post-term pregnancy and when deciding elective delivery, knowledge about gestational age is essential. However, criticism has been raised against its routine use to determine gestational age. Ultrasound is subject to a certain degree of variation, as is determination of gestational age on the basis of the last menstrual period. Variation is less by ultrasound, which therefore reduces the number of "post-term" pregnancies. The consequences of post-term pregnancy are discussed.

Eight hundred and nineteen patients were evaluated at greater than or equal to 280 days' gestation. All patients underwent nonstress test (NST) and breast stimulation to induce contraction stress test (CST), except where contraindicated. If CST was nonqualifying (less than three contractions per ten minutes), Pitocin (oxytocin) was used to complete the CST if there was a nonreactive NST. Delivery was instituted for any abnormal CST, even with a reactive NST, based on the last test within seven days of delivery. There were 747 reactive NST and 72 nonreactive NST. Breast stimulation for CST was done in 655 instances--315 (48 per cent) had nonqualifying CST and 340 (52 per cent) had qualifying CST. There was an increased incidence of induction in the nonqualifying CST group and abnormal CST group. There were no statistically significant differences in perinatal outcomes in the group with reactive NST, irrespective of the CST result. There were no antepartum fetal deaths.

The serum of rats at mid-pregnancy contains at least 2 distinct placental lactogen (PL)-like substances tentatively termed placental lactogen-alpha (PL-alpha) and placental lactogen-beta (PL-beta) (Endocrinol Japon 38: 533-540, 1991). We have investigated the secretory patterns of three placental lactogens (PL-alpha, PL-beta and placental lactogen-II) during normal pregnancy and in two prolonged-pregnancy models. Pregnancy was prolonged by the introduction of new corpora lutea by inducing ovulation on day 15 of pregnancy by successive treatments with PMSG (30 IU/rat, sc on day 12) and hCG (10 IU/rat, iv on day 14), and in the second model by progesterone implants on day 15 of pregnancy. During normal pregnancy, each of the 3 PLs exhibited only one secretory peak in the serum; PL-alpha and PL-beta on day 12 and placental lactogen II (PL-II) on day 20. Interestingly, in the rats with new sets of corpora lutea, serum PL-alpha and PL-beta levels began to increase again on day 18 and showed peaks on day 20 for PL-alpha and on day 22 for PL-beta. In this model, the initiation of PL-II secretion was not affected, but high levels were maintained until day 26, when parturition occurred. In rats receiving either PMSG or hCG, the secretory patterns of the PLs were similar to as those during normal pregnancy.(ABSTRACT TRUNCATED AT 250 WORDS)

To assess the correlation between Doppler velocimetry and perinatal outcome in the postdates pregnancy, 75 women who were at least 41 weeks' gestation were evaluated twice weekly until delivery. Evaluation included Doppler velocimetry of the umbilical and uterine-arcuate arteries, as well as nonstress testing and amniotic fluid volume estimation. The mean umbilical artery systolic-diastolic ratio (S/D) was significantly higher in the pregnancies with subsequent abnormal perinatal outcomes than in those with normal outcomes (2.42 versus 2.19; P = .03). Using a receiver operating characteristic curve, an abnormal umbilical artery S/D was defined as 2.40 or greater. Using this value, sensitivity was 57.1% and specificity was 77.8%. Our study suggests that an umbilical artery S/D of 2.40, rather than the more traditionally accepted cutoff of 3.0, may be a useful threshold to identify those postdates pregnancies at high risk for abnormal perinatal outcome.

Post-date pregnancy is associated with higher rates of perinatal mortality and morbidity. The purpose of the present study was to compare the outcome of 200 post-date pregnancies, managed according to our protocol, to a matched control group of 200 healthy pregnant women delivered at term. The management protocol was based mainly on the pelvic score and nonstress test. Higher rates of labor induction, meconium-stained amniotic fluid, fetal distress, instrumental deliveries and cesarean sections were found in post-date pregnancies than in the control group (40% vs. 3% P = 0.0001, 31% vs. 15.5% P = 0.00001, 18.5% vs. 9.5% P = 0.007, 8% vs. 3% P = 0.02, 12.5% vs. 4% P = 0.002 respectively). Neonatal birth weight in the study group was significantly higher than in the control group (3,484.3 +/- 410.7 vs. 3,218.4 +/- 407.8 g P less than 0.001). Despite these differences between the groups, the perinatal morbidity and mortality rates were similar. These results can be partially attributed to the early antenatal monitoring and intensive follow-up.

This study examines the efficiency of Doppler flow velocity waveform analysis in the evaluation of the postdate pregnancy. Seventy women whose pregnancies were at or beyond 41 weeks' gestation were assessed by calculating the systolic/diastolic ratios from umbilical and uteroplacental arteries. Waveform ratios from pregnancies associated with fetal compromise and abnormal neonatal outcome were similar to those from pregnancies in which the outcome was normal. These findings indicate that the pathophysiology of placental insufficiency in postdate pregnancies differs from that observed in cases of fetal growth retardation at earlier gestational ages. Doppler flow velocity waveform analysis is unlikely to be of benefit in the routine assessment of the postdate pregnancy.

Postmaturity is associated with an increased risk of fetal distress and of intrauterine fetal death. In order to assess the probability of the occurrence of postdate delivery, we have determined the Bishop score and measured the cervical distensibility index (CDI) using a cervicotonometer in 52 normal pregnant primiparous women between 37 and 40 weeks of pregnancy. 16 out of the 52 patients delivered after 41 weeks. Bishop scores and CDI were significantly lower in women who delivered after term than in those who delivered at or before 41 weeks (p less than 0.05; Student's test). The patients who had both a low Bishop score (less than or equal to 4) and a CDI less than 4 cm.kg-1 delivered after 41 weeks in 73% of the cases. Those who had a Bishop score less than or equal to 4 associated with a CDI greater than 4 cm.kg-1 delivered at or before 41 weeks in 80% of the cases. These results confirm the etiologic role of incomplete cervical maturation in postdate pregnancies. CDI measurement associated with the Bishop score could permit selection of the patients who would benefit from pharmacological cervical ripening.

In 20 women, the umbilical artery flow velocity waveform (FVW) was recorded immediately before and 30-40 min after administering vaginal or extraamniotic prostaglandin E2 to ripen the cervix. Maternal plasma concentrations of prostaglandin E2 (PGE2) and prostaglandin F2 alpha (PGF2 alpha) metabolites (bicyclo-PGEM and PGFM, respectively) were measured at the time of the Doppler recordings. The administration of prostaglandin E2 was associated with a significant rise in maternal plasma PGFM and bicyclo-PGEM concentrations, but there was no change in the umbilical artery FVW Pulsatility index (PI). These results suggest that cervical ripening with local prostaglandin E2 has no effect on the umbilical artery FVW.

Pregnancies that extend beyond 42 weeks of gestation have a higher risk for uteroplacental insufficiency than do pregnancies delivered prior to this time. Postterm infants are at risk for meconium aspiration due to uteroplacental insufficiency. Prior research has shown that postterm infants are at risk for temperature- and glucose-regulating difficulties following birth. In this study, the abilities of 63 postterm infants and 88 term infants to regulate temperature and glucose during the first 24 hours of infant age were compared. No significant differences were found in the two groups on the two variables.

The postdate pregnancy remains an unresolved clinical problem with the threat of medicolegal consequences in cases of unfavorable outcome. Placental dysfunction leading to fetal hypoxia may develop in these pregnancies at any time and for the truly postmature fetus there is a considerable risk of asphyxia. Fetal hypoxia, accompanied with hemoconcentration due to a maternofetal fluid imbalance, leads to diminished fetal urine production and a reduced amniotic fluid volume, which can cause cord compression. According to this simplified pathophysiological cascade, the monitoring of postdate pregnancies should be based mainly on ultrasound assessment of amniotic fluid volume and cardiotocography. At our institution, instead of an obligatory induction of labor at a fixed gestational age, induction is performed when the largest amniotic fluid pocket measures less than 3 cm (vertical) or when variable decelerations of the fetal heart rate appear. A nonreactive nonstress test calls for a complete biophysical profile. As long as these monitoring techniques indicate fetal well-being, pregnancy is allowed to continue, especially in the presence of an incompatible condition of the cervix.

Objective: To determine the proper management of pregnancy in uncomplicated cases going beyond 42 weeks., Design: Randomized controlled trial of induction of labor at or shortly after the 42-week limit, versus close monitoring without induction except when indicated for medical reasons., Setting: Hospital's obstetrical department, Study Population: 188 pregnant women, randomly allocated to two groups with 94 in each., Interventions: Induction of labor by stripping of membranes and i.v. oxytocin infusion, with artificial rupture of membranes when the cervical opening was 3 cm or more in diameter. The control group was followed with clinical, biochemical and electronic tests, intervention being applied according to needs., End Points: Frequency and modes of operative delivery, maternal and perinatal morbidity and mortality., Main Results: The distribution of gestational age (in weeks) at birth was almost identical in the two groups, but there were more operative deliveries in the control group than in the induction group (64 versus 48, p less than 0.05). Maternal complications and perinatal morbidity rates were equally distributed between the groups. There was one perinatal death in the induction group and two deaths among the controls., Conclusion: With due reservation for small numbers, routine induction after term may result in fewer operative deliveries. No other advantage has been demonstrated when compared with close monitoring and intervention when medically indicated.

In this preliminary investigation, we sought evidence of increasing impedance to placental blood flow from both sides of the placenta and evidence of compromised fetal aortic blood flow in 35 human pregnancies exceeding 42 weeks' gestation. Fetal age was confirmed by biparietal diameter (BPD) measurements obtained before 21 weeks. Pourcelot's Index, calculated from Doppler sonograms recorded with a noninvasive technique from small arteries in the myometrium and from an umbilical cord artery, did not correlate with the duration of the pregnancy beyond term. However, this "resistance index" of Pourcelot was higher in the umbilical cord arteries of fetuses with a worse clinical outcome. Doppler blood cell velocity in the fetal descending aorta correlated significantly and negatively with the prolongation of gestation. Fetal aortic velocities appeared to be lower in fetuses who passed meconium before delivery. Our findings suggest that fetal compromise in prolonged pregnancy is more a fetal-placental problem than a uteroplacental problem.