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Monday, October 11, 2010

PREGNANCY SEROTINUS

DEFINITION
Pregnancy serotinus is a pregnancy that lasted 42 weeks (294 days) or more, calculated from the first day of last menstrual cycle 28 days or 280 days (40 weeks) from day of conception. Another term often used is overdue pregnancy, postmaturitas, delayed pregnancy, postdatism or postdates. Approximately 10% of pregnancies continue until 42 weeks, 4% continued until the age of 43 weeks.

DIAGNOSIS
Determination of gestational age based on the formula Naegele, calculated from the first day of last menstrual period and based on the menstrual cycle (estimated delivery is 280 days or 40 weeks from the first day of last menstrual cycle 28 days or 266 days after ovulation). So to determine the pregnancy gestation serotinus must be known precisely. Naegele formula is still commonly used, but must keep in mind the various factors that may affect / result in errors of calculation, namely:
1. Determination of gestational age based on the first day of last period is often not easy because the mother could not remember the date of the first day of last menstrual period with certainty.
2. Determining the time of ovulation is not easy.
3. Factors that affect the calculation, such as menstrual cycle variations, the calculation error by the mother, and so forth.
Apart from menstruation, pregnancy age determination can be assisted by a clinical re-evaluate the age at first pregnancy from mother to come. The earlier a pregnancy examination performed, gestational age has come closer to the truth. Clinicians also need to ask when was the movement of children or take measurements in serial fundus uteri. Examination of high serial fundus uteri in pregnancy serotinus will show a decline, because the fetus is not growing larger while the amniotic fluid began to decrease. Mother also felt fetal movement decrease the frequency and intensity.
Ultrasound examination is very helpful estimated gestational age. With the ultrasound gestational age can be determined more accurately by the deviation is only more or less a week. But there is also a problem in multiple pregnancies / twins because each fetus will be smaller than in normal singleton pregnancies.
In Indonesia, the diagnosis of pregnancy serotinus very difficult because many mothers do not know the date of the last menstrual period properly. A good diagnosis can only be made if the patient checked out since the beginning of pregnancy.

ETIOLOGY
Experiments on animals show that pregnancy causes serotinus is a combination of maternal and child factors. Factors that affect pregnancy serotinus, namely:
1. Factors placenta: placental sulfatase deficiency of the enzyme
2. Factors children: adenokortikotropik hormone deficiency (ACTH)
3. Maternal factors. Although there is no obvious explanation, there are several factors that allegedly associated with pregnancy serotinus, such as age, parity, state serotinus seosioekonomi and history of previous pregnancies. According to the study, the incidence of pregnancy serotinus increased from 10% to 27% in women with a history of pregnancy serotinus before and to 39% in women with two previous serotinus pregnancy history.

CLINICAL
Postmaturitas syndrome is a term used to describe the clinical state of infants who showed more months of pregnancy. This situation occurs in 30% of pregnancies serotinus and 3% pregnancy term.
Signs serotinitas:
1. Disappearance of subcutaneous fat
2. Dry skin, wrinkles or cracks
3. Meconium staining of the skin, umbilicus and amniotic membrane
4. Nails and long hair
5. Lazy baby
6. Face looked old and worried-looking
In some cases even exceed 42 weeks gestational age, placental function remains good, resulting in a large baby (> 4000 grams). The incidence in pregnancy is 37-41 weeks was 1.4% and increased to 2.2% at 42 weeks gestation or more.

COMPLICATION
Complications that can occur is the death of the fetus in the uterus (due to placental insufficiency) and neonatal mortality. The fetus also can suffer from hypoxia, hypovolemia, acidosis, breathing distress syndrome, hypoglycaemia or adrenal hipofungsi.
Placental function peaking at gestational age 38-42 weeks, then decreased after 42 weeks, seen from the decreasing levels of estrogen and placental laktogen. Also occur placental spiral arteries spasm. As a result of supply disruption could occur oxygen and nutrients to live and intrauterine fetal growth and development. Circulation uteroplasenta reduced to 50%. By histopathology, placental abnormalities found were calcification, villous edema, pseudohiperplasia on sinsitium, degeneration of fibroids in placental villi and mikroinfark. The volume of amniotic fluid also decreases because the absorption is taking place. These circumstances are conditions that are not good for the fetus.
Asphyxia is a major cause of neonatal mortality and morbidity. In neonates with serotinus autopsy found the petekie the pleura and pericardium, which is a sign of hypoxia and found the existence of particles of meconium in the lungs.

ASSESSMENT ANTEPARTUM
Given the high morbidity and mortality in pregnancy serotinus, an assessment of the risk of antepartum dismaturitas must be done to decide whether the fetus was still allowed to stay in the womb (waiting for spontaneous labor) or to be born.
Assessment of fetal well-being can be done by:
1. Evaluation of amniotic fluid by amniocentesis or ultrasound (also for checking biometric).
2. Monitor changes in fetal heart rate with no load (nonstress test) or with a load (contraction stress test). Test with a load no-load test performed if non rektif. If the result is unsatisfactory or suspicious, the test was repeated 24 hours later.
3. Determine the biophysical profile scoring obtained from the NST and ultrasound examination to see the fetal heart rate, fetal breathing, fetal tone, fetal movement and the amount of amniotic fluid. It must be remembered that there is no way of monitoring fetal well-being of the most ideal, so it must be a combination of different ways.
In addition to fetal welfare assessment, inspection also needs to be done to assess the degree of maturity of the cervix, using the Bishop score. It is necessary to determine further action.

TREATMENT
1. Ekspektatif, therefore induction of labor associated with the incidence of uterine inertia, long deliveries, cervical trauma, cesarean section deliveries made and, in some cases, particularly with the immature cervix, ekspektatif care needs to be done, provided that good fetal condition. This is based on:
    a. 60% of pregnancies will end in spontaneous labor at gestational age 40-41 weeks and 80% at 43 weeks gestation.
    b. With the advancement of medical technology for monitoring the welfare of the fetus, the fetus can still be retained in the uterus during the situation is still good.
2. Active, without seeing the state of the cervix, induction should be performed on fetuses that have a risk for experiencing postmaturitas syndrome or when the pregnancy reaches 308 days of age (44 weeks). Pregnancy should also be immediately terminated if the biophysical profile scoring 0-2, found oligohydramnios (<2 cm in greatest sac or amniotic fluid index <5), variable decelerations encountered in no-load test, load test results with positive, ripe cervix (Bishop score > 6), there PJT or patients with complications such as preeclampsia or diabetes mellitus.
Genesis long obstructed labor, uterine inertia hypotonic and fetal distress during labor will increase, so that the induction of pregnancy serotinus intrapartum monitoring should be more stringent. Induction can be performed with oxytocin by intravenous drip or by the use of prostaglandin preparations.
In some cases even exceed 42 weeks gestational age, placental function remains good, resulting in a large baby (> 4000 grams) that can complicate delivery. In this case the action performed cesarean section.
At the time of delivery, amniotic fluid state is considered important. If meconium staining has occurred or even coagulation with blackish green, so baby born resuscitation should be done immediately. Ideally directly performed tracheal intubation and rinsing

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