Clinical Considerations and Recommendations Are there interventions that decrease the rate of post-term pregnancy? Obtaining an accurate EDD using ultrasonography early in the pregnancy can reduce the incidence of pregnancies diagnosed as post-term and minimize unnecessary interventions. However, routine early ultrasonography has not been recommended as standard care in the United States.
There is no evidence to show that stimulation of the breasts and nipples affects the incidence of post-term pregnancy. There is conflicting evidence as to the effectiveness of sweeping the membranes at term in reducing post-term pregnancy. When should antepartum fetal testing begin? Although evidence shows that antenatal fetal surveillance for post-term pregnancies does not decrease perinatal mortality, it has become a common, universally accepted practice.
Antenatal fetal surveillance also is often performed between 40 and 42 weeks of gestation, despite there being no randomized controlled trial demonstrating that it results in an improvement in perinatal outcome. The authors add that, because of ethical and medicolegal issues, no studies have included post-term patients who were not monitored. What form of antenatal surveillance should be performed, and how frequently should a post-term patient be reevaluated? Options for evaluating fetal well-being include, nonstress testing, biophysical profile BPP or modified BPP nonstress test plus amniotic fluid volume estimation , contraction stress testing, and a combination of these modalities.
None of these methods has been shown to be superior. Assessment of amniotic fluid volume appears to be important; however, a consistent definition of low amniotic fluid in the post-term pregnancy has not been established. There is no proven benefit to monitoring the post-term fetus with Doppler velocimetry. The authors state that no recommendation can be made regarding the frequency of antenatal surveillance; however, many practitioners use twice-weekly testing.
As soon as data from the last menstrual period, the first accurate ultrasound examination, or both are obtained, the gestational age and the estimated due date EDD should be determined, discussed with the patient, and documented clearly in the medical record. Subsequent changes to the EDD should be reserved for rare circumstances, discussed with the patient, and documented clearly in the medical record. When determined from the methods outlined in this document for estimating the due date, gestational age at delivery represents the best obstetric estimate for the purpose of clinical care and should be recorded on the birth certificate.
For the purposes of research and surveillance, the best obstetric estimate, rather than estimates based on the last menstrual period alone, should be used as the measure for gestational age. Recommendations The American College of Obstetricians and Gynecologists, the American Institute of Ultrasound in Medicine, and the Society for Maternal—Fetal Medicine make the following recommendations regarding the method for estimating gestational age and due date: If pregnancy resulted from assisted reproductive technology ART , the ART-derived gestational age should be used to assign the estimated due date EDD.
For instance, the EDD for a pregnancy that resulted from in vitro fertilization should be assigned using the age of the embryo and the date of transfer. As soon as data from the last menstrual period LMP , the first accurate ultrasound examination, or both are obtained, the gestational age and the EDD should be determined, discussed with the patient, and documented clearly in the medical record.
For the purposes of research and surveillance, the best obstetric estimate, rather than estimates based on the LMP alone, should be used as the measure for gestational age. Introduction An accurately assigned EDD early in prenatal care is among the most important results of evaluation and history taking. This information is vital for timing of appropriate obstetric care; scheduling and interpretation of certain antepartum tests; determining the appropriateness of fetal growth; and designing interventions to prevent preterm births, postterm births, and related morbidities.
Appropriately performed obstetric ultrasonography has been shown to accurately determine fetal gestational age 1. If a transabdominal examination is inconclusive, a transvaginal scan or transperineal scan is recommended. This may be especially useful in imaging the fetal brain structures when the head lies deep within the maternal pelvis or when a low-lying placenta is obscured by shadowing.
Fetal cardiac activity, fetal number, and fetal presentation should be reported. Any abnormal heart rates or rhythms should be reported. An abnormal finding on second-trimester ultrasonography that identifies a major congenital anomaly significantly increases the risk of genetic abnormality and warrants further counseling, including the discussion of various prenatal testing strategies. Multiple gestations require the documentation of this additional information: Ultrasonography can detect abnormalities in amniotic fluid volume.
An estimate of amniotic fluid volume should be reported. Although it is acceptable for experienced examiners to qualitatively estimate amniotic fluid volume, semiquantitative methods also have been described for this purpose eg, amniotic fluid index [AFI] and single deepest pocket and are preferred because of their reproducibility. The placental location, appearance, and relationship to the internal cervical os should be recorded.
It is recognized that apparent placental position early in pregnancy may not correlate with its location at the time of delivery. Therefore, if a low-lying placenta or placenta previa is suspected early in gestation, verification in the third trimester by repeat ultrasonography is indicated. If an anterior placenta previa or low-lying placenta is found in a patient with a prior cesarean delivery, the possibility of abnormal implantation, including placenta accreta, should be considered.
Transabdominal, transvaginal, or transperineal views may be helpful in assessing cervical length or visualizing the internal cervical os and its relationship to the placenta. Transvaginal or transperineal ultrasonography should be considered if the cervix appears shortened.
Methods for Estimating the Due Date
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