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12 lbsSwing-Arm™ Scatter Shield® provides lower extremity protection for personnel close to the tube. 24″ W x 32″ L lead shield swings 180° along table. Ideal for cardiac cath, special studies, electrophysiology and the O.R. Available with mounting block for radiology tables or without block to mount on O.R. tables with standard side rail socket (sold separately). ½ ” diameter round mounting post adjusts shield vertically 18″ . Wipes clean. Blue vinyl. Provides lower extremity protection for personnel close to the tube . Lead shield swings 180° along table . Ideal for cardiac cath, special studies, electrophysiology and the OR

PACS Radiology Table

PACS Radiology Table  Heavy-duty, tubular steel construction with tilting front and large concave waterfall surface to eliminate sharp edges and corners. 78″ x 46″ adjustable, split work surface goes from 24″ to 50″ w/height memory. Weight capacity of 300-lbs per work surface. Heavy-duty, tubular steel construction. Adjustable split work surface. Weight capacit of 30 lbs per work surface

The test involves injecting a very small dose of a radioactive chemical, called a radiotracer, into the vein of your arm. The tracer travels through the body and is absorbed by the organs and tissues being studied. Next, you will be asked to lie down on a flat examination table that is moved into the center of a PET scanner—a doughnut-like shaped machine. This machine detects and records the energy given off by the tracer substance and, with the aid of a computer, this energy is converted into three-dimensional pictures. A physician can then look at cross-sectional images of the body organ from any angle in order to detect any functional problems.

What problems can a PET scan detect?

A PET scan can measure such vital functions as blood flow, oxygen use, and glucose metabolism, which helps doctors identify abnormal from normal functioning organs and tissues. The scan can also be used to evaluate the effectiveness of a patient’s treatment plan, allowing the course of care to be adjusted if necessary.

Currently, PET scans are most commonly used to detect cancer, heart problems (such as coronary artery disease and damage to the heart following a heart attack), brain disorders (including brain tumors, memory disorders, seizures) and other central nervous system disorders.

How is a PET scan different from a CT or MRI scan?

One of the main differences between PET scans and other imaging tests like CT scan or magnetic resonance imaging (MRI) is that the PET scan reveals the cellular level metabolic changes occurring in an organ or tissue. This is important and unique because disease processes often begin with functional changes at the cellular level. A PET scan can often detect these very early changes whereas a CT or MRI detect changes a little later as the disease begins to cause changes in the structure of organs or tissues.

How should I prepare for a PET scan?

A PET scan is usually done on an outpatient basis. Your doctor will give you detailed instructions on how to prepare for your scan, including what you may or may not eat or drink before your exam. Before undergoing the scan, be sure to tell your doctor of any medications—prescription and over-the-counter—that you are taking as well as any herbal medications and vitamins. If you are taking certain medications or have certain diseases, such as diabetes, you will be given specific instructions regarding preparation for your scan. Generally, most patients are told not to eat anything for a minimum of 6 hours before the scan. Heart patients are also told to not take any product with caffeine for at least 24 hours. Be sure to wear comfortable clothes to your appointment. You may be asked to change into a hospital gown during the test. In those patients that need an assessment of the area near the bladder, a bladder catheter may need to be inserted.

It is essential to tell your doctor if you are pregnant or think you might be pregnant before undergoing a PET scan because of radiation exposure.

How long does the test take?

Once injected into a vein, it typically takes from 45 minutes to 1 hour for the radiotracer to travel throughout the body and be absorbed into the organs or tissues to be examined. The scan itself may take another 30 to 60 minutes. The heart and brain studies take less time for imaging. You will be asked to remain still for the entire length of the exam, since motion will reduce the quality of the images. Depending on which organ is being examined, there may be additional tests and additional dyes or chemicals used that may lengthen the total appointment time up to 3 to 4 hours. For example, patients being examined for heart disease may undergo a stress test in which PET scans are obtained while at rest followed by the administration of other drugs to examine blood flow to the heart under exercise conditions.

Does the PET scan pose any risks?

Although a radiotracer chemical is used in this test, the amount of radiation you are exposed to is low. The dose of tracer used is so small that it does not affect the normal processes of the body. However, the radiotracer may expose the fetus of patients who are pregnant or infants of women who breastfeed to the radiation. You and your doctor need to consider this risk compared with the need for and potential information to be gained from the PET scan.

How soon will the scan results be available?

A radiologist who has specialized training in PET scans will interpret the images, write a report, and deliver the results to your doctor. This process usually takes 2 to 3 days.

© Copyright 1995-2009 The Cleveland Clinic Foundation. All rights reserved.

Few years ago there were very few treatment options available for lung cancer. Recent years have witnessed a dramatic increase in the selection of drugs that are effective against lung cancer. Some where during the last few years the mode of treatment for lung cancer have shifted from the traditional non-specific forms of chemotherapy to more specific targeted therapy. In the last few years we have seen FDA approvals for two targeted therapies for lung cancer namely Geftinib (Iressa) and Erlotinib (Tarceva).

More and more targeted therapies are in pipeline for lung cancer. It looks like the monstrous lung cancer is slowly getting defeated. Nimotuzumab (TheraCIM) is a monoclonal antibody directed against the EGF receptor (similar in action to Iressa). Nimotuzumab has demonstrated very encouraging results in both children and adults with brain cancer. Now YM BioSciences, manufacturer of Nimotuzumab, is proceeding to clinical trials in lung cancer using this new drug. The proposed randomized Non-Small-Cell Lung Cancer (NSCLC) trial will compare the effects of the combination of nimotuzumab with radiation against radiation alone in selected patients with stage IIB and III disease. This drug is also currently undergoing a Phase II monotherapy trial in Europe in patients with advanced metastatic pancreatic cancer.” A recent study using nimotuzumab in combination with radiation therapy for nasopharyngeal cancer patients has completed in China and has demonstrated substantial benefit. Based on this finding nimotuzumab resulting in drug approved for sale in China.

…to stop breastfeeding?
…to drink water?
…to drink cow’s milk and eat dairy foods?
…to drink juice?
…to eat wheat or rice baby cereal?
…to eat solid foods?
…to eat fish or sushi?
…to eat honey?
…to eat strawberries?
…to eat peanuts and other nuts?

Experts: Daina Kalnins is a registered dietitian and academic and clinical specialist working at the Hospital for Sick Children in Toronto. She is the author of Better Breastfeeding (Robert Rose) and YUM due out April 2008 (Lobster Press). Joanne Saab is a registered dietitian practicing in paediatrics at McMaster Children’s Hospital in Hamilton, Ont. Together Daina and Joanne have co-authored Better Baby Food, Better Food for Kids and Better Food for Pregnancy (Robert Rose).

…to stop breastfeeding?
The World Health Organization, as well as the Canadian Paediatric Society, Dietitians of Canada and Health Canada, recommend that babies be breastfed exclusively for at least six months and continue until at least one year of age while solid foods are being introduced.

…to drink water?
For the first six months, babies need only breastmilk or formula, after which, solids are introduced. Water can be encouraged along with expressed breastmilk or formula at nine to 10 months of age. Limit water to two to four ounces.

…to drink cow’s milk and eat dairy foods?
Cow’s milk does not contain an adequate amount of iron, so it is not recommended as the milk of choice until after one year, when other foods containing iron are a part of the diet. Dairy products, such as grated cheese, plain yogurt and cottage cheese, are a terrific source of energy, calcium and protein and can be introduced around the age of six months.

…to drink juice?
Juice is not recommended as a beverage for infants. Save the juice for when your child is at least four or five years of age, or offer diluted juice occasionally (not daily). Keep in mind that too much juice can decrease appetite for solid foods and increase risk of dental caries.

…to eat wheat or rice baby cereal?
Cereals can be introduced after six months in combination with breastmilk or formula. Introducing commercial varieties of cereal, in conjunction with breastmilk, will help ensure your child is getting the necessary amount of iron in his diet.

…to eat solid foods?
Solids can be introduced at six months. Meat or infant cereals are recommended as first choices as they are high in iron, compared to fruit and vegetables. Recent evidence indicates that there is no need to delay solid foods in order to prevent allergies as this can just postpone the emergence of the allergy. If there is allergy in the family, however, discuss introduction of the more allergenic foods (fish, eggs, milk etc.) with your physician.

…to eat fish or sushi?
Raw fish is not recommended for babies or young children. It may contain bacteria that their digestive system may not be able to handle. Cooked fish, however is a great source of protein and essential fatty acids and can be introduced after the age of six months. Boneless fish is often a great option for infants because its soft and flaky texture makes it very easy to chew.

…to eat honey?
Honey should not be offered to infants until after one year of age because it may contain the spores of a bacterium called Clostridium botulinum. These spores may be harmful to a baby, who is not yet able to handle this pathogen.

…to eat strawberries?
Strawberries and other berries can be introduced at the same time as other fruits and vegetables, around six months of age. As with all new foods it is recommended that only one new food be introduced every two to three days so that if an allergic reaction were to occur, it would be easy to identify which food was the source of the reaction.

…to eat peanuts and other nuts?
Nut butters, like peanut butter, or foods containing nuts, can be introduced before 12 months, but butters should be thinly spread on bread or a cracker to prevent an infant from gagging. Whole nuts, however, should not be given to young children (under the age of five years) because they are a choking hazard. The small, hard, round shape of nuts is the perfect size to block a young child’s airway. In some cases doctors recommend delaying the introduction of peanuts or nut products if there is a history of allergies within the family. Talk to your doctor about what’s best for your family.

*Please note that the information provided should be used a guideline. If you’re concerned about a something specific always consult your family doctor or paediatrician.

Originally published in Todaysparent.com, March 2008

The episiotomy tradition

For many years, an episiotomy was thought to help prevent more extensive vaginal tears during childbirth — and heal better than a natural tear. The procedure was also thought to reduce the risk of incontinence after childbirth and keep the bladder and rectum from drooping into the vagina.

Sounds reasonable, but researchers have found that routine episiotomies don’t prevent these problems after all. Recovery is uncomfortable, and sometimes the surgical incision is more extensive than a natural tear would have been. For some women, an episiotomy causes pain during sex in the months after delivery. An episiotomy also increases the risk of fecal incontinence after delivery.

The new approach

Researchers say there’s no need for a routine episiotomy, but the procedure is still warranted in some cases. Your health care provider may recommend an episiotomy if:

• Extensive vaginal tearing appears likely
• Your baby is in an abnormal position
• Your baby needs to be delivered quickly

If you need an episiotomy, you’ll receive an injection of a local anesthetic to numb the tissue if you haven’t had any other type of anesthesia or your anesthesia is no longer numbing the area. You won’t feel your health care provider making the incision or repairing it after delivery.

The role of tissue massage

To soften the vaginal tissues for delivery, some health care providers suggest massaging the area between the vaginal opening and anus in the last weeks of pregnancy. This is known as perineal massage. Although there are no guarantees — and you don’t have to do it if the idea makes you uncomfortable — stretching the tissues may reduce vaginal trauma during delivery.

Start by washing your hands thoroughly with soap and hot water. Make sure your nails are trimmed. Then rub a mild lubricant, such as K-Y jelly, on your thumbs. Place your thumbs just inside your vagina and press downward toward your rectum. Hold for one to two minutes. Then, slowly massage the lower half of your vagina. Repeat the massage once a day for 10 minutes at a time until delivery.

Your partner can help, if you wish. It’s normal to feel a little burning or other discomfort as you stretch your perineum. Stop if you feel sharp pain.

Healing from an episiotomy

If you have an episiotomy or tear during delivery, the wound may hurt for a week or two — especially when you walk or sit. If the incision or tear is extensive, the tenderness may last longer. Any stitches used to repair the episiotomy will usually be absorbed on their own. In the meantime, you can help promote healing:

• Soothe the wound. Use an ice pack, or wrap ice in a washcloth. Chilled witch hazel pads may help, too. Witch hazel is the main ingredient in many hemorrhoid pads. You can find witch hazel pads in most pharmacies.
• Keep the wound clean. Use a squirt bottle to rinse the tissue between the vaginal opening and anus with water after using the toilet. Soak in a warm tub.
• Take the sting out of urination. Squat rather than sit to use the toilet. Pour warm water over your vulva as you’re urinating.
• Prevent pain and stretching during bowel movements. Hold a clean pad firmly against the wound and press upward while you bear down. This will help relieve pressure on the wound.
• Sit down carefully. To keep your bottom from stretching, squeeze your buttocks together as you sit down. If sitting is uncomfortable, use a doughnut-shaped cushion to ease the pressure.
• Do your Kegels. These exercises help tone your pelvic floor muscles. Simply tighten your pelvic muscles as if you’re stopping your stream of urine. Starting about a day after delivery, try it for five seconds at a time, four or five times in a row. Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions. Aim for at least three sets of 10 repetitions a day. You can do Kegels while standing, sitting or lying down — even while breast-feeding your baby.
• Use medication as needed. Your health care provider may order prescription medications or recommend an over-the-counter pain reliever or stool softener.
• Look for signs of infection. If the pain intensifies or the wound becomes hot, swollen and painful or produces a pus-like discharge, contact your health care provider.

Accept some uncertainty

It’s important to go into labor with an open mind. It will take time for the baby to stretch the vaginal tissues to allow delivery, and sometimes the baby needs to be delivered before the vaginal tissues can stretch on their own. Count on your health care provider to respect your wishes about episiotomy — and to let you know when it’s the safest option for you or your baby.

Typically, people with salmonella infection develop diarrhea, fever and abdominal cramps within 12 to 72 hours. Signs and symptoms of salmonella infection generally last four to seven days. Most healthy people recover without specific treatment.

In some cases, the diarrhea associated with salmonella infection can be extremely dehydrating and require prompt medical attention. Life-threatening complications may also develop should the infection spread beyond your intestines. Your risk of salmonella infection is higher if you travel to countries with poor sanitation.

There are more than 2,000 varieties of salmonella bacteria, but only about a dozen of them cause illnesses in people. Most of these illnesses can be classified as gastroenteritis, often featuring severe diarrhea. But a few varieties of salmonella bacteria result in typhoid fever, a sometimes deadly disease that is more common in developing countries.

Gastroenteritis
Salmonella-induced gastroenteritis is most often caused by eating raw or undercooked meat, poultry, eggs or egg products. The incubation period ranges from several hours to two days. Signs and symptoms may include:

• Nausea
• Vomiting
• Abdominal pain
• Diarrhea
• Fever
• Chills
• Headache
• Muscle pains
• Blood in the stool

Typhoid fever
Most people who develop typhoid fever in the United States have recently traveled in a country where the disease is more common. The incubation period ranges from five to 21 days following infection. Signs and symptoms may include:

• Diarrhea or constipation
• Fever over 102 F (38.8 C)
• Slightly raised, rose-colored spots on your upper chest
• Cough
• Mental confusion
• A slowing of your heartbeat
• Enlargement of your liver and spleen

Salmonella infection itself isn’t life-threatening. However, in certain people — especially children, older adults, transplant recipients and people with a weakened immune system — the development of complications can be dangerous.

Dehydration
If you can’t drink enough liquids to replace the fluid you’re losing from persistent diarrhea, you may become dehydrated. Warning signs include:

• Sunken eyes
• Dry mouth and tongue
• Reduced production of tears
• Decreased urine output

Bacteremia

If salmonella infection enters your bloodstream (bacteremia), it can infect tissues throughoutyour body, including:

• The tissues surrounding your brain and spinal cord (meningitis)
• The lining of your heart or valves (endocarditis)
• Your bones or bone marrow (osteomyelitis)

Reactive arthritis
People who have had salmonella are at higher risk of developing reactive arthritis. Also known as Reiter’s syndrome, reactive arthritis typically causes:

• Eye irritation
• Painful urination
• Painful joints

Medications

• Antidiarrheals. Medications like loperamide (Imodium) can help relieve cramping, but they may also prolong the diarrhea associated with salmonella infection.
• Antibiotics. If your doctor suspects that salmonella bacteria have entered your bloodstream, he or she may prescribe antibiotics to kill the bacteria.

Salmonella infection is contagious, so take precautions to avoid spreading bacteria to others. Preventive methods are especially important when preparing food or providing care for infants, older adults and people with compromised immune systems.

Wash your hands
Washing your hands thoroughly can help prevent the transfer of salmonella bacteria to your mouth or to any food you’re preparing. Wash your hands after you:

• Use the toilet
• Change a diaper
• Handle raw meat or poultry
• Clean up pet feces
• Touch reptiles or birds

Keep things separate

• Store raw meat, poultry and seafood away from other foods in your refrigerator
• If possible, have two cutting boards in your kitchen - one for raw meat and the other for fruits and vegetables
• Never place cooked food on an unwashed plate that previously held raw meat

Avoid eating raw eggs
Cookie dough, homemade ice cream and eggnog all contain raw eggs. If you must consume raw eggs, ensure that they have been pasteurized.

If you develop these problems, they’re likely to begin about five to 10 days after you start antibiotic therapy and to end within two weeks after you stop taking antibiotics. Sometimes, however, diarrhea and other symptoms may not appear for days or even weeks after you’ve finished antibiotic treatment.

When the overgrowth of harmful bacteria is severe, you may have signs and symptoms of colitis or pseudomembranous colitis, such as:

• Frequent, watery diarrhea
• Abdominal pain and cramping
• Fever, often higher than 101 F (38.3 C)
• Pus in your stool
• Bloody stools
• Nausea
• Dehydration

Most people experience an improvement within two weeks after beginning treatment for colitis or pseudomembranous colitis. However, sometimes signs and symptoms recur — usually within a month of the initial treatment — which means you may need to be treated a second or even a third time.

Which antibiotics cause AAD?
Virtually any antibiotic can cause antibiotic-associated diarrhea, colitis or pseudomembranous colitis, but the most common culprits are ampicillin, clindamycin and cephalosporins such as cefpodoxime (Vantin).

Sometimes erythromycins (Erythrocin), quinolones (Cipro, Floxin) and tetracyclines also can cause antibiotic-associated diarrhea. Problems can occur whether you take the antibiotics by mouth or receive them by injection.

Call your doctor right away if you experience the following signs and symptoms:

• Several episodes of loose stools or watery diarrhea for two or more consecutive days
• Fever
• Severe abdominal pain or cramping
• Pus or blood in your stool
• Lightheadedness or dizziness

These signs and symptoms may indicate a number of conditions, ranging from viral, bacterial or parasitic infections to inflammatory bowel disorders, such as ulcerative colitis or Crohn’s disease. In older adults with cardiovascular disease, low blood flow to the colon (ischemic colitis) also can cause these symptoms.

But if you’re currently taking antibiotics or have recently finished antibiotic therapy, it’s possible you have antibiotic-associated diarrhea. Your doctor can perform tests to determine the exact cause of your problem.

Mild antibiotic-associated diarrhea isn’t likely to cause any lasting problems. But pseudomembranous colitis can lead to life-threatening complications, including:

• A hole in your bowel (bowel perforation). This results from extensive damage to the lining of your large intestine. The greatest risk of a perforated bowel is that bacteria from your intestine will infect your abdominal cavity (peritonitis).
• Toxic megacolon. In this condition, your colon becomes unable to expel gas and stool, causing it to become greatly distended (megacolon). Signs and symptoms of toxic megacolon include abdominal pain and swelling, fever and weakness. You may also become groggy or disoriented. Left untreated, your colon can rupture, causing bacteria from your colon to enter your abdominal cavity. A ruptured colon requires emergency surgery and in some cases may be fatal.
• Dehydration. Severe diarrhea can lead to excessive loss of fluids and electrolytes — substances such as sodium, potassium and chloride, which are essential for transmitting nerve impulses, making your muscles contract, and maintaining proper levels of fluid in and around your cells. Extreme fluid loss can cause seizures and shock — a condition in which your tissues don’t receive enough oxygen. Signs and symptoms of dehydration include a very dry mouth, intense thirst, little or no urination, and extreme weakness.

Mild diarrhea
If you have mild diarrhea, your symptoms are likely to clear up within a few days to two weeks after your antibiotic treatment ends. In the meantime, your doctor may recommend drinking plenty of liquids to prevent dehydration and avoiding foods that may aggravate your symptoms. When diarrhea is more severe, your doctor may stop your antibiotic therapy and wait for your diarrhea to subside.

Severe diarrhea
In cases of very severe diarrhea, colitis or pseudomembranous colitis, you’re likely to be treated with the drug metronidazole (Flagyl), which is usually taken in tablet form for 10 days. If metronidazole isn’t effective, or you’re pregnant or breast-feeding, you’ll receive another drug, vancomycin (Vancocin).

Both metronidazole and vancomycin are antibiotics that effectively control C. difficile. Vancomycin was once the drug of choice for treating antibiotic-associated diarrhea, but it’s very expensive and now usually reserved for the most resistant cases. However, vancomycin is recommended for pregnant and lactating women because metronidazole has not been proved safe in fetuses and infants.

Some people treated for pseudomembranous colitis have a recurrence of diarrhea and need further treatment.

Probiotics: More research needed
The term “probiotic” means “for life.” It generally refers to concentrated supplements of beneficial bacteria similar to those that occur naturally in your intestinal tract. Most probiotic supplements are formulated to survive the digestive process and the highly acidic conditions in your stomach.

Probiotic supplements may help prevent antibiotic-associated diarrhea, but study results have been mixed. Some studies have shown probiotic supplements to be effective in preventing or reducing antibiotic-associated diarrhea, while others have not. More research is needed before probiotics can be routinely recommended for antibiotic-associated diarrhea.

Probiotic formulas are available in liquid and capsule form in drugstores and natural food stores and in some grocery stores. Many need refrigeration. In addition, commercial yogurt labeled as having live cultures contains certain “good” bacteria, such as Lactobacillus acidophilus, that may help reduce the incidence and severity of antibiotic-associated diarrhea.

Another probiotic, the yeast Saccharomyces boulardii, has been shown to help protect against pseudomembranous colitis. This yeast, taken orally, is used in Europe to help prevent antibiotic-associated diarrhea and may also prevent recurrences of the disease.

Capsules of S. boulardii are available in the dietary supplement Florastor, in natural food stores and some drugstores. Although S. boulardii rarely causes side effects, avoid it if you have a yeast allergy. And if you have HIV/AIDS, talk to your doctor before trying this product

Although pregnancy is said to last nine months, healthcare providers track pregnancy by weeks and days. The normal duration of pregnancy is approximately 37 to 42 weeks, with the estimated due date at 40 weeks or 280 days from the first day of the last menstrual period.

A postterm pregnancy, also called a prolonged pregnancy, is one that has extended beyond 42 weeks from the first day of the last menstrual period. As many as 10 percent of pregnancies are postterm.

Accurate dating — It is essential to ensure that the pregnancy is in fact postterm. Ideally, an accurate gestational age is determined early in the pregnancy. In women who have regular menstrual periods, the date can often be reliably calculated based on the last period.

If there is uncertainty about the dates, or if the size of the woman’s uterus is larger or smaller than expected based on the date of the last period, the gestational age of the fetus and due date can be estimated based upon findings on fetal ultrasound examination. This estimate is most accurate when performed early in pregnancy; ultrasounds performed in the last half of pregnancy are less reliable for estimating the due date.

POSTTERM PREGNANCY CAUSES

In most cases, the cause of postterm pregnancy is unknown. There are some factors that place a woman at increased risk. The incidence is higher in first pregnancies and in women who have had a previous postterm pregnancy. Genetic factors may also play a role. One study showed an increased risk of postterm pregnancy in women who were, themselves, born postterm.

However, variations in when a woman ovulates can lead to errors in calculating the true duration of pregnancy and lead to over- and underestimations of when the baby is due. An ultrasound examination performed in the first one-half of pregnancy is the most reliable method of calculating the date the baby is due, especially in women with long or irregular menstrual cycles.

POSTTERM PREGNANCY RISKS

Pregnancy that continues beyond 42 weeks is associated with risks to the fetus and the mother.

Risks to the fetus

Stillbirth or neonatal death — The incidence of stillbirth or infant death is increased in pregnancies that continue beyond 42 weeks. However, the risk is relatively small, with only 4 to 7 deaths per 1000 deliveries. By comparison, the risk of stillbirth or infant death in pregnancies between 37 and 42 weeks is 2 to 3 per 1000 deliveries.

Large body size — Postterm fetuses have a greater chance of developing complications related to larger body size (called macrosomia), which is defined as weighing more than 4500 grams, or about 10 pounds. Complications can include prolonged labor, difficulty passing through the vagina, and birth trauma (eg, fractured bones or nerve injury) related to difficulty in delivering the shoulders (shoulder dystocia).

Fetal dysmaturity — Also called “postmaturity syndrome,” this refers to a fetus whose growth in the uterus has been restricted, usually due to a problem with delivery of blood to the fetus through the placenta. This puts the fetus at increased risk for umbilical cord compression, problems after birth such as breathing problems, and long-term neurologic problems.

Meconium aspiration — Beyond term, the fetus is more likely to have a bowel movement, called meconium, into the amniotic fluid. If the fetus is stressed, there is a chance it will inhale some of this meconium stained amniotic fluid; this can cause breathing problems or infection when the baby is born.

Risks to the mother — Risks to the mother are related to the larger size of postterm infants, and include difficulties during labor, an increase in injury to the perineum (including the vagina, labia, and rectum), and an increased rate of cesarean birth with its associated risks of bleeding, infection, and injury to surrounding organs.

POSTTERM PREGNANCY TREATMENT

Antenatal fetal monitoring — In most cases, a healthcare provider will recommend tests on the fetus if the pregnancy extends beyond the due date. These tests give information about the health of the fetus and about the risks or benefits of allowing the pregnancy to continue.

The American College of Obstetricians and Gynecologists has stated that it is only necessary to start antenatal fetal monitoring after 42 weeks (294 days) of gestation, although many obstetric care providers will start fetal testing at 41 weeks. Many experts recommend twice weekly testing, including a measurement of amniotic fluid volume. Testing may also include observing the fetus’ heart rate using a fetal monitor (called a nonstress test) or observing the baby’s activity with ultrasound (called a biophysical profile).

Nonstress testing — Nonstress testing is done by monitoring the baby’s heart rate with a small device that is placed on the mother’s abdomen. The device uses sound waves (ultrasound) to measure the baby’s heart rate over time, usually for 20 to 30 minutes. Normally, the baby’s baseline heart rate should be between 110 and 160 beats per minute and should increase above its baseline by at least 15 beats per minute for 15 seconds when the baby moves.

The test is considered reassuring (called “reactive”) if two or more fetal heart rate increases are seen within a 20 minute period. Further testing may be needed if these increases are not observed after monitoring for 40 minutes.

Biophysical profile — A biophysical profile (BPP) score is calculated to assess the fetus’ health. It consists of five components, nonstress testing and ultrasound measurement of four fetal parameters: fetal body movements, breathing movements, fetal tone (flexion and extension of an arm, leg, or the spine), and amniotic fluid volume (table 1). Each component is scored individually, 2 points if normal and 0 points if not normal. The maximum possible score is 10.

Amniotic fluid volume is an important variable in the BPP because a low volume (called oligohydramnios) may increase the risk of umbilical cord compression and may be a sign of changes in the feto-uteroplacental circulation. Amniotic fluid level can become reduced within a short time period, even a few days.

Contraction stress test — A contraction stress test (CST) can also be done to assess fetal health. It involves giving an intravenous medication (oxytocin) to the mother to induce uterine contractions. The fetus’ heart rate is monitored in response to the contractions. A fetus whose heart rate slows down during a CST may require a cesarean delivery.

Inducing labor — The optimal time to deliver a baby in a woman who is postterm is sometimes hard to determine. The healthcare provider and woman must consider the risks and benefits of continuing the pregnancy, the results of antenatal testing, and the condition of the cervix (the lower part of the uterus, which opens into the vagina). Normally, the cervix begins to dilate (open) and efface (thin) towards the end of a woman’s pregnancy. Inducing labor is more likely to fail in women whose cervix is not dilated or thinned (called ripe), which could require the woman to undergo cesarean birth.

Most healthcare providers will induce labor if it does not begin spontaneously by 41 to 42 weeks of gestation. For a woman whose cervix is not ripe, labor can be induced with a medication applied directly to the cervix, which causes it to ripen. Cervical ripening may also be accomplished using mechanical methods such as laminaria (a small rod made of dried seaweed) or a Foley catheter bulb. Most women, including those whose cervix is ripe, will also require an intravenous medication, oxytocin, which stimulates the uterus to contract; uterine contractions further stimulate cervical dilation and effacement. If induction of labor does not completely dilate and efface the cervix, or if complications develop that require the baby to be delivered quickly, a cesarean delivery is usually performed.

Some patients may choose to have a cesarean delivery, especially if the fetus is macrosomic (defined as an estimated fetal weight of greater than or equal to 4500 grams [about 10 pounds]), they have a history of previous cesarean delivery, or for reasons of personal choice. It is important to understand the risks and benefits of cesarean delivery, and to discuss these issues with the physician who will be performing the procedure. (See “Patient information: Cesarean delivery”.)

POSTTERM INFANTS

Some postterm infants have a distinctive appearance. The arms and legs may be long and thin. The skin may appear dry and parchment-like, with peeling and sometimes meconium staining. The skin may appear loose, especially over the thighs and buttocks. Scalp hair may be longer or thicker, and the fingernails and toenails may be long. Postterm newborns are typically very alert, and may have a “wide-eyed” look.

Few studies have examined long-term outcomes (eg, growth and development patterns, intelligence) of postterm infants. In general, the outcome appears similar in both postterm and term infants.

SUMMARY

• A postterm pregnancy is one that extends beyond 42 weeks from the first day of the last menstrual period; as many as 10 percent of pregnancies are postterm.
• The chance of postterm pregnancy is higher in first pregnancies and in women who have had a postterm pregnancy in the past. Genetic factors may also play a role. (See ‘Postterm pregnancy causes’ above.)

• There are certain risks associated with postterm pregnancy. The chance of stillbirth or infant death increases slightly, and the fetus may develop problems due to having restricted space in the uterus or inhaling meconium (bowel movement). The increased size of the fetus can lead to complications, some of which can affect the mother during delivery. (See ‘Postterm pregnancy risks’ above.)

• Tests are used to monitor the health of a postterm fetus and the safety of allowing the pregnancy to continue. (See ‘Antenatal fetal monitoring’ above.)

• For most women, labor is induced if it has not occurred by 41 to 42 weeks. Some women will elect to have a cesarean delivery if the fetus has grown to a very large size. (See ‘Inducing labor’ above.)

• Some postterm infants have a distinctive appearance, with long and thin arms, dry and sometimes loose-appearing skin, and longer hair and nails. Postterm infants tend to be very alert at birth. (See ‘Postterm infants’ above.)