Graviditas prolongata

Graviditas prolongata Charlotte Wilken-Jensen (tovholder), Pernille Danneskiold Lassen, Tine Greve, Annette Wind Olesen, Tom Weber, Misan Anne Cathrine Stehouwer, Dorthe Louise Ahrenkiel Thisted, Laura Hauerberg, Anya Sook Goldmann Eidhammer, Anette Kjærbye Thygesen, Marie Diness, Christina Norrbom, Jan Stener Jørgensen Guideline-gruppen Graviditas prolongata 2009 bestod af : Charlotte Wilken-Jensen (tovholder), Ole Bredahl Rasmussen, Lillian Kempf, Jacob Lauesgaard Nielsen, Pernille Danneskiold Lassen, Tine Greve, Annette Wind Olesen Guidelinen forholder sig til kontrol og behandling af kvinder med graviditas prolongata, herunder hvornår det anbefales at igangsætte fødslen, men ikke igangsætningsmetoder. Guidelinen om graviditas prolongata inkluderer gravide før uge 42+0, idet der ikke er noget entydigt begreb for uge 41+0, og risici ved stigende gestationsalder antages at være et kontinuum. Indhold Resume af guideline 2 Forkortelser 4 Baggrund 4 Definition 4 Prævalens 4 Årsager 4 Komplikationer ved GP 5 Perinatale 5 Maternelle 5 Intrauterin død 6 Føtal overvågning 8 Igangsættelse 8 Komplikationer ved igangsættelse 8 side 1

Risiko for akut sectio ved igangsættelse 9 Igangsættelse 41 eller 42 uger? 11 Selektiv igangsættelse (eller AMOR-IPOT) 12 Kvinders holdning 14 Igangsættelse på maternal request 15 Igangsættelse ved sectio antea 16 Igangsættelse ved IVF graviditeter 17 Appendix AMOR-IPOT 19 Referencer 21 Resume af guideline Graviditas prolongata (GP) defineres af WHO som en graviditet med en gestationslængde på 294 dage eller derover. Der er få kendte årsager til postterm fødsel. Nulliparitet, tidligere postterm fødsel, maternel overvægt og en genetisk komponent øger risikoen (B). GP øger risikoen for: o Perinatale komplikationer, som placentainsufficiens, mekoniumafgang, skulderdystoci, mekoniumaspiration, fetal distress og nedsat apgar (B). o Maternelle komplikationer, som dystoci, obstetriske traumer, sectio og postpartum blødning (B). o Perinatal død, idet risikoen for intrauterin død stiger allerede fra 37-38 uger og accentueres efter 40-41 uger. I særlig risiko er førstegangsfødende, ældre gravide, overvægtige og kvinder af lav social klasse (B). 2

Føtal overvågning kan bestå af CTG og vurdering af fostervandsmængde ved UL 1-2 gange om ugen fra uge 41+0 (C). Obstetriske retningslinjer for føtal overvågning kan udarbejdes, afhængig af lokale forhold. Planlagt igangsættelse uge 41+0 versus uge 42 +0: o Planlagt igangsættelse efter 41+0 eller 42+0 synes at være stort set ligeværdig med hensyn til perinatal mortalitet og svær morbiditet (A). Antallet af børn med mekonium aspirationssyndrom nedsættes dog ved igangsættelse uge 41+0 (A). Igangsættelse i uge 41+0 eller 42+0 kan iværksættes efter den enkelte afdelings retningslinjer. o Planlagt igangsættelse efter 41+0 øger ikke risikoen for akut sectio (B). o Ved høj maternel alder >= 40 år øges risikoen for intrauterin fosterdød, hvorfor igangsættelse uge 41+0 anbefales (C). o Ved svær overvægt (BMI >35) øges risikoen for intrauterin fosterdød, hvorfor igangsættelse i uge 41+0 og senest uge 42+0 kan anbefales (D). o Ved singleton IVF/ICSI graviditet kan man overveje at sætte i gang tidligere end normalt grundet den øgede perinatale mortalitet sammenlignet med spontant undfanget singleton. Det vides dog ikke om den øgede perinatale mortalitet også ses ved høj gestationsalder (D). o Mange gravide foretrækker igangsættelse uge 41+0 frem for afventende holdning og kontrol (B). o Igangsættelse på mors ønske synes ikke at være skadeligt (D). Ved sectio antea anbefales: o Gravide med lav risiko for ruptur (interval mellem fødsler over 18 mdr. og tidligere succesfuld VBAC) der har et ønske om VBAC og ingen andre risikofaktorer for dårligt outcome, kan sættes i gang senest uge 42+0 efter afdelingens gældende retningslinjer (D). o Gravide med høj risiko for ruptur (interval mellem fødsler under 18 mdr. eller ikke tidligere succesfuld VBAC) anbefales forløsning ved elektivt sectio, hvis fødslen ikke er gået spontant i gang senest uge 42+0 (D). 3

Forkortelser AFI GP IVF ICSI IUD IUGR VBAC Amnion Fluid Index Graviditas Prolongata In Vitro Fertilitation Intra Cytoplasmatisk Sperm Injektion Intrauterin Død Intrauterine Growth Restriction Vaginal Birth After Cesaerian section Baggrund Definition Graviditas prolongata er af WHO defineret som en graviditet med en gestationslængde på 294 dage eller derover, dvs. uge 42+0 eller derover (1977). Prævalens Prævalensen af graviditas prolongata (GP) afhænger af patientsammensætningen. Andelen af førstegangsfødende samt hyppigheden af præterm fødsel, elektivt sectio og igangsættelse er nogle af de vigtigste faktorer. Først og fremmest afhænger prævalensen af den metode, der anvendes til terminsfastsættelse. Beregnet ved tidlig UL-skanning er den 2-4 % (Tunon, Eik-Nes et al., 1996;Savitz, Terry, Jr. et al., 2002). Prævalensen i Danmark var knap 6 % i 2006-9 (Sundhedsstyrelsens sundhedsstatistik). Årsager Der er få kendte årsager til postterm fødsel (Shea, Wilcox et al., 1998). Sjældne årsager til postterm fødsel er anencephali, placenta sulfatase insufficiens, manglende fosterhypofyse og føtal binyrehypoplasi (Cunningham FG, MacDonald PC et al., 1989), og ved alle tilstande mangler den høje koncentration af østrogen som ses ved normal graviditet. 4

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