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Author: Aaron B Caughey, MD, PhD, MPH; Chief Editor: David Chelmow
Updated: Oct 22, 2013
Postterm pregnancy is defined as a pregnancy that extends to 42 0/7 weeks and beyond. [1] The
reported frequency of postterm pregnancy is approximately 3-12%. [1, 2] However, the actual biologic
variation is likely less since the most frequent cause of a postterm pregnancy diagnosis is inaccurate
dating.[3, 4, 5, 6] Risk factors for actual postterm pregnancy include primiparity, prior postterm pregnancy,
male gender of the fetus, and genetic factors.[7, 8, 9, 2, 1, 10]
Laursen et al studied monozygotic and dizygotic twins and their subsequent development of
prolonged pregnancies. They found that maternal but not paternal genetic factors influenced the rate
of postterm pregnancies and accounted for the etiology in as many as 30% of these pregnancies. [11] A
more recently described risk factor is obesity, which appears to increase the risk of pregnancies
progressing beyond 41 or 42 weeks of gestation.[12, 13, 14]
Although the last menstrual period (LMP) has been traditionally used to calculate the estimated due
date (EDD), many inaccuracies exist using this method in women who have irregular cycles, have
been on recent hormonal birth control, or who have first trimester bleeding. In particular, women are
more likely to be oligo-ovulatory than polyovulatory, so cycles longer than 28 days are not
uncommonly seen.[4] If such a cycle is 35 days instead of 28 days, a second trimester ultrasound will
not be powerful enough to redate the pregnancy. Thus, not only the LMP date, but the regularity and
length of cycles must be taken into account when estimating gestational age.
Ultrasonographic dating early in pregnancy can improve the reliability of the EDD; however, it is
necessary to understand the margin of error reported at various times during each trimester. A
calculated gestational age by composite biometry from a sonogram must be considered an estimate
and must take into account the range of possibilities.
Estimation range varies. For example, crown-rump length (CRL) is 3-5 days, ultrasonography
performed at 12-20 weeks of gestation is 7-10 days, at 20-30 weeks is 2 weeks, and after 30 weeks is
3 weeks. Thus, a pregnancy that is 35 weeks by a 31-week ultrasound could actually be anywhere
from 32 weeks to 38 weeks (35 wk +/-3 wk). If the calculated ultrasonographic gestational age varies
from the LMP more than the respective range of error, it is used instead to establish the final EDD.
The importance of determining by what method a pregnancy is dated cannot be overemphasized
because this may have significant consequences if the physician delivers a so-called term pregnancy
that is not or observes a so-called term pregnancy that is very postterm.
When determining a management plan for an impending postterm pregnancy (>40 wk of gestation but
< 42 wk), the 3 options are (1) elective induction of labor, (2) expectant management of the
pregnancy, or (3) antenatal testing. Each of these 3 options may be used at any particular time during
this 2-week period.
Note that if the pregnancy is at risk for an adverse outcome from an underlying condition, either
maternal or fetal, inducing labor may proceed without documented lung maturity. Also, an elective
induction of labor may proceed at or after 39 weeks of gestation in the absence of documented lung
maturity provided that 36 weeks have elapsed since documentation of a positive human chorionic
gonadotropin (+hCG) test finding, 20 weeks of fetal heart tones have been established by a fetoscope
or 30 weeks by a Doppler examination, or 39 weeks' gestation have been established by a CRL or by
an ultrasound performed before 20 weeks of gestation consistent with dates by the patient's LMP.
Meconium aspiration syndrome refers to respiratory compromise with tachypnea, cyanosis, and
reduced pulmonary compliance in newborns exposed to meconium in utero and is seen in higher
rates in postterm neonates.[40] Indeed, the 4-fold decrease in the incidence of the meconium aspiration
syndrome in the United States from 1990-1998 has been attributed primarily to a reduction in the
postterm delivery rate[22] with very little contribution from conventional interventions designed to protect
the lungs from the chemical pneumonitis caused by chronic meconium exposure, such as
amnioinfusion[41, 42] or routine nasopharyngeal suctioning of meconium-stained neonates. [43]
Postterm pregnancy is also an independent risk factor for neonatal encephalopathy [44] and for death in
the first year of life.[17, 18]
While much of the work above has been conducted in postterm pregnancies. Some of the fetal risks
such as presence of meconium, increased risk of neonatal acidemia, and even stillbirth have been
described as being greater at 41 weeks of gestation and even at 40 weeks of gestation as compared
with 39 weeks gestation.[23, 24] For example, in one study, the rates of meconium and neonatal acidemia
both increased throughout term pregnancies beyond 38 weeks of gestation. In addition to stillbirth
being increased prior to 42 weeks of gestation, one study found that the risk of neonatal mortality also
increases beyond 41 weeks of gestation.[45]Thus, 42 weeks does not represent a threshold below
which risk is uniformly distributed. Indeed, neonatal morbidity (including meconium aspiration
syndrome, birth injury, and neonatal acidemia) appears to be the lowest at around 38 weeks and
increase in a continuous fashion thereafter.[46]
While preterm delivery is a well-established risk factor for cerebral palsy, a recent study suggested
that delivery at 42 weeks or later is also associated with increased risk (RR 1.4, 95% CI, 1.2-1.6 when
compared with delivery at 40 weeks gestation). [47]
In addition to the medical risks, the emotional impact (anxiety and frustration) of carrying a pregnancy
1-2 weeks beyond the estimated due date should not be underestimated. In a randomized, controlled
trial of women at 41 weeks of gestation, women who were induced would desire the same
management 74% of the time, whereas women with serial antenatal monitoring only desired the same
management 38% of the time.[49]
Similar to neonatal outcomes, maternal morbidity also increases in term pregnancies prior to 42
weeks of gestation. Such complications as chorioamnionitis, severe perineal lacerations, cesarean
delivery rates, postpartum hemorrhage, and endomyometritis all increase progressively after 39
weeks of gestation.[24, 31, 32, 33, 22]
Timing of Delivery
The first decision that must be made when managing an impending postterm pregnancy is whether to
deliver. In certain cases (eg, nonreassuring surveillance, oligohydramnios, growth restriction, certain
maternal diseases), the decision is straightforward. In these high-risk situations, the time at which the
risks of remaining pregnant begin to outweigh the risks of delivery may come at an earlier gestational
age (eg, 39 weeks of gestation). However, frequently several options can be considered when
determining a course of action in the low-risk pregnancy. The certainty of gestational age, cervical
examination findings, estimated fetal weight, patient preference, and past obstetric history must all be
considered when mapping a course of action.
The main argument against a policy of routine induction of labor at 41 0/7 to 41 6/7 weeks has been
that induction increases the rate of cesarean delivery without decreasing maternal and/or neonatal
morbidity. Some of the studies that failed to show a reduction in fetal/neonatal morbidity were diluted
by poorly dated pregnancies that were not necessarily postterm. In addition, the potential for
increasing the risk for cesarean delivery with a failed induction is far less likely in the era of safe and
effective cervical ripening agents.
To date, more than 10 studies have been published of elective induction of labor, many of them at 41
weeks of gestation.[50, 35, 51, 52, 53, 54] The preponderance of the evidence from these studies, including
meta-analyses, find that not only is rate of cesarean delivery not increased in women who were
randomized to routine induction of labor, but also more cesarean deliveries were performed in the
noninduction groups, and the most frequent indication was fetal distress. Even with multiple studies,
very few neonatal differences have been demonstrated. However, the reduction in meconium is
statistically significant and the rate of neonatal mortality is lower.
In summary, routine induction at 41 weeks of gestation does not increase the cesarean delivery rate
and may decrease it without negatively affecting perinatal morbidity or mortality. In fact, both the
woman and the neonate benefit from a policy of routine induction of labor in well-dated, low-risk
pregnancies at 41 weeks' gestation. Because it is associated with a lower rate of adverse outcomes,
including shoulder dystocia and meconium aspiration syndrome, this policy may also prove to be
more cost-effective.[55]
A policy of routine induction at 40 weeks' has few benefits, and there are multiple reasons not to allow
a pregnancy to progress beyond 42 weeks.
Prior to 41 weeks of gestation, the evidence becomes more scant with only 3 small, non-US,
randomized, controlled trials comparing elective induction of labor to expectant management of
pregnancy.[53] However, elective induction of labor is increasingly being used as a management
strategy.[56, 57] While this management may be reasonable in a practice that allows 48 hours or more for
the management of the latent phase and the first stage of labor overall, in a setting where induction of
labor is called a failure after 18-24 hours, it will likely further increase the cesarean delivery rate.
spontaneous onset of labor, a reduction in operative vaginal delivery, cesarean delivery rates, or
maternal or neonatal morbidity has not been consistently proven. [58, 59, 60]
Unprotected sexual intercourse causes uterine contractions through the action of prostaglandins in
semen and potentially release of endogenous prostaglandins similar to stripping of the membranes.
Indeed, prostaglandins were originally isolated from extract of prostate and seminal vesicle glands,
hence their name. Despite some conflicting data, it appears that unprotected coitus may lead to the
earlier onset of labor, reduction in postterm pregnancy rates, and less induction of labor.[61, 62, 63]
In a small randomized trial that attempted to address this question, women were randomized to a
group advised to have coitus versus a control group that was not. In this study, the women advised to
have coitus did so more often (60% vs 40%), the difference in the rate of spontaneous labor was not
measurable in this underpowered study.[64] Similarly, the efficacy of acupuncture for induction of labor
cannot be definitively assessed because of the paucity of trial data; this requires further examination.
[65, 66]
rapidly. Care should also be taken when using combinations of mechanical and pharmacologic
methods of cervical ripening.
Once an induction of labor has begun, watch for the major potential complications associated with
inductions beyond 41 weeks' gestation and have a plan for dealing with each. Complications include
the presence of meconium, macrosomia, and fetal intolerance to labor.
The further the pregnancy progresses beyond 40 weeks, the more likely it is that significant amounts
of meconium will be present. This is due to increased uteroplacental insufficiency, which leads to
hypoxia in labor and activation of the vagal system. In addition, the presence of a smaller amount of
amniotic fluid increases the relative concentration of meconium in utero.
Traditionally, saline amnioinfusion and aggressive nasopharyngeal and oropharyngeal suctioning at
the perineum were used to decrease the risk of meconium aspiration syndrome. Recent studies
contradict this standard practice. Fraser et al performed a prospective, randomized, multicenter study
evaluating the risks and benefits of amnioinfusion for the prevention of meconium aspiration
syndrome.[42] They concluded that in clinical settings, which have peripartum surveillance,
amnioinfusion of thick meconium-stained amniotic fluid did not decrease the risk of moderate-tosevere meconium aspiration syndrome, perinatal death, or other serious neonatal disorders compared
with expectant management. In addition, other recent studies have shown that deep suctioning of the
airway at the perineum does not effectively prevent meconium aspiration syndrome, contrary to
popular belief.
Fetal macrosomia can lead to maternal and fetal birth trauma and to arrest of both first- and secondstage labor. Because the risk of macrosomia increases throughout term and postterm pregnancies,
one of the most important parts of the delivery plan is being prepared for shoulder dystocia in the
event that this unpredictable, anxiety-provoking, and potentially dangerous condition arises. To
prepare such an event, experienced clinicians should be present at the delivery, a stool/step next to
the delivery bed should be placed to help with suprapubic pressure, and the maneuvers to reduce the
shoulder dystocia should be reviewed.
Finally, intrapartum fetal surveillance in an attempt to document fetal intolerance to labor before it
leads to acidosis is critical. Whether continuous fetal monitoring or intermittent auscultation is used,
interpretation of the results by a well-trained clinician is of paramount importance. If the fetal heart rate
tracing is equivocal, fetal scalp stimulation and/or fetal scalp blood sampling may provide the
reassurance necessary to justify continuing the induction of labor. If the practitioner cannot find
reassurance that the fetus is tolerating labor, cesarean delivery is recommended.
No single method of antenatal surveillance has been shown to be superior to any other. Options
include a nonstress test, contraction stress test, full biophysical profile, modified biophysical profile
(nonstress test and amniotic fluid index), or a combination of these modalities. Evaluation of the
amniotic fluid level has been shown to be especially important because of demonstrated increased
adverse pregnancy outcomes. Therefore, delivery should be implemented in the event of
oligohydramnios with or without other nonreassuring tests. Doppler ultrasonography has been shown
to provide no proven advantage for evaluating postdate or postterm pregnancies and should not be
routinely used.
A modified biophysical profile has been shown to be as sensitive as a full biophysical profile. Boehm
et al demonstrated that twice-weekly testing of patients at risk for fetal distress was superior to weekly
testing, decreasing the rate of stillbirth from 6.1 per 1000 live births to 1.9 per 1000.
In summary, the use of a nonstress test and an amniotic fluid index 2 times per week for pregnancies
continuing past 41 weeks is reasonable. In addition, if any indication during antepartum surveillance
leads the practitioner to question the intrauterine environment, delivery should be expedited.
Summary
The management of postterm pregnancies is complicated and fraught with complex issues. The
decision of whether to induce labor or to proceed with expectant management with or without
antepartum fetal surveillance is not taken lightly. Data support inducing labor at 41 weeks' gestation in
an accurately dated, low-risk pregnancy, regardless of cervical examination findings. This strategy,
although not without its critics, averts the need for antepartum fetal surveillance and does not increase
the cesarean delivery rate; in fact, it may decrease the cesarean delivery rate.
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Vahratian A, Zhang J, Troendle JF, et al. Labor progression and risk of cesarean delivery in
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Xenakis EM, Piper JM, Conway DL, et al. Induction of labor in the nineties: conquering the
unfavorable cervix. Obstet Gynecol. Aug 1997;90(2):235-9. [Medline].
Yeast JD, Jones A, Poskin M. Induction of labor and the relationship to cesarean delivery: A
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Yoder BA, Gordon MC, Barth WH Jr. Late-preterm birth: does the changing obstetric paradigm
alter the epidemiology of respiratory complications?. Obstet Gynecol. Apr 2008;111(4):814-22
http://emedicine.medscape.com/article/261369-overview#a30 post term pregnancy
Hanan El Marroun1,2,*,
Mijke Zeegers1,3,
Eric AP Steegers4,
Jan van der Ende1,
Jacqueline J Schenk5,
Albert Hofman6,
Vincent WV Jaddoe2,6,7,
Frank C Verhulst1 and
Henning Tiemeier1,6,8
+ Author Affiliations
1.
1.
Next Section
Abstract
Background Post-term birth, defined as birth after pregnancy duration of 42 weeks,
is associated with increased neonatal morbidity and mortality. The long-term
consequences of post-term birth are unknown. We assessed the association of postterm birth with problem behaviour in early childhood.
Methods The study was performed in a large population-based prospective cohort
study in Rotterdam, The Netherlands. Pregnant mothers enrolled between 2001 and
2005. Of a cohort of 5145 children, 382 (7%) were born post-term, and 226 (4%)
were born preterm. Parents completed a standardized and validated behavioural
checklist (Child Behavior Checklist, CBCL/1.55) when their children were 1.5 and 3
years old. We examined the relation between gestational age (GA) at birth, based on
early fetal ultrasound examination, and problem behaviour with regression analyses,
adjusting for socio-economic and pregnancy-related confounders.
Results A quadratic relationship between GA at birth and problem behaviour
indicates that both preterm and post-term children have higher behavioural and
emotional problem scores than the term born children. Compared with term born
children, post-term born children had a higher risk for overall problem behaviour
[odds ratio (OR)=2.10, 95% confidence interval (CI)=1.323.36] and were almost
two and a half times as likely to have attention deficit / hyperactivity problem
behaviour (OR=2.44, 95% CI=1.384.32).
Conclusions Post-term birth was associated with more behavioural and emotional
problems in early childhood, especially attention deficit / hyperactivity problem
behaviour. When considering expectant management, this aspect of post-term
pregnancy should be taken into account.
Key words
Post-term birth
preterm birth
childhood
Previous SectionNext Section
Introduction
Timely onset of labour is important for peri- and post-natal health. Both preterm
(<37 weeks of gestation) and post-term birth (42 weeks of gestation) are
associated with neonatal morbidity and mortality.13 Local management protocols
with regard to elective caesarean delivery and labour induction affect the prevalence
of post-term birth. Overall, labour induction before or at 42 weeks of gestation has
increased,1 but post-term births still occur relatively frequently (up to 510%), even
in industrialized countries.3,4 Accurate pregnancy dating is critical to the diagnosis of
post-term births.3,4 Routine use of ultrasound to confirm pregnancy dating can
decrease occurrence of post-term birth.5 Common risk factors for post-term birth
include obesity, nulliparity and prior post-term birth and rare causes include
placental sulphatase deficiency (an X-linked recessive disorder characterized by low
estriol levels), fetal adrenal hypoplasia or insufficiency and trisomy 16 and 18. 1,2,6,7
The long-term problems associated with preterm birth, such as increased incidence
of cerebral palsy, sensory impairments and behavioural problems are well
known.8 The studies investigating effects of post-term birth have focused on the risks
during pregnancy and delivery.9 Post-term birth increased the risk of neonatal
encephalopathy and death during the first year of life,5,10 but the long-term
consequences are unclear. One of the few studies performed found that post-term
born infants did not differ from controls at age 2 years regarding general intelligence,
physical milestones and illnesses.11 However, a recent study using referral to a
neurologist or psychologist as indicator of developmental problems found that 13%
of children born post-term had a neurological or developmental disorder at the age
of 5 years.12
In this population-based prospective study, we hypothesize that post-term birth is
related to behavioural and emotional problems in preschool children. In order to
examine the specificity of the association between post-term birth and problem
behaviour, we examined specific behavioural and emotional problems including
attention deficit / hyperactivity disorder problems (ADHD), affective problems and
pervasive developmental problems.
Previous SectionNext Section
Preterm birth was defined as birth before 37 weeks gestation (N=226) and postterm birth was defined as birth after 42 weeks gestation (N=382). As an additional
comparison group, we defined a group of children born before 35 weeks of gestation
(N=78) which is normally included in cohorts of preterm babies.
The Child Behavior Checklist for toddlers (CBCL/1.55) was used to obtain
standardized parental reports of childrens behavioural and emotional
problems.15,16 The CBCL was a postal questionnaire and sent to be filled out by the
mother when the child was 18 months old and again when the child was 36 months
old. At 36 months of age, we also asked the father to fill out the CBCL. Each item (99
items in total) is scored on a three-point scale (0=not true, 1=somewhat or
sometimes true and 2=very true or often true), based on the childs behaviour
during the preceding 2 months. The sum of all problem items is the Total Problems
score. There are five Diagnostic and Statistical Manual of Mental Disorders (DSM)oriented scales: anxiety problems, affective problems, pervasive developmental
problems, ADHD and oppositional defiant problems. It has been shown that these
DSM-oriented scales provide accurate and supplementary information on clinical
diagnoses.17 Also, good reliability and validity have been reported for the CBCL. 16 We
used the clinical cut-off scores (91st percentile for the Total Problems score and 98th
percentile for the syndrome scales) to classify children as having behavioural
problems in the clinical range.17 When parents filled out the questionnaire, they were
not aware of our research question exploring the relation between post-term birth
and behavioural problems, but parents generally are aware of the GA of their child
and the risks associated with preterm birth. The maternal CBCL Total Problems
ratings at 18 months and 36 months were correlated (r=0.58, P<0.001). Maternal
and paternal CBCL Total Problems ratings at 36 months were correlated (r=0.56, P<
0.001).
Several covariates were considered in the analyses and were chosen based on the
existing literature and effect estimate changes. Maternal weight and height were
measured at intake. We used postal questionnaires to obtain information on mothers
parity, ethnicity and family income. Maternal ethnicity was defined according to the
classification of Statistics Netherlands.18 Educational level was categorized into three
levels: primary, secondary and higher education.19 Information about maternal
smoking and alcohol use was obtained by questionnaires in each trimester. Based on
these questionnaires, maternal smoking or drinking were categorized into no, until
pregnancy was known and continued during pregnancy as described
previously.20 The Brief Symptom Inventory (BSI) was used to assess maternal
psychopathology in mid-pregnancy; the BSI is a validated self-report questionnaire,
which defines a spectrum of psychiatric symptoms.21 Registries provided information
on obstetric variables such as induction, birthweight, mode of delivery, umbilical
artery pH and Apgar scores after 1 and 5min. The post-natal questionnaire
administered at age 6 and 12 months was used to gather information on
breastfeeding and frequency of day care use.
For descriptive analyses, children were categorized in three groups based on GA: (i)
born after 37 weeks of gestation up to and including 41 weeks and 6 days (term,
reference group); (ii) born after <37 weeks of gestation (preterm); and (iii) born after
42+0 weeks of gestation or more (post-term). Chi-square and t-tests were used to
compare maternal and child characteristics. To test the associations between GA and
behavioural problems, we used linear regression models with GA as a continuous
variable. We used the generalized estimating equation (GEE) to analyse the relation
of GA with the behavioural and emotional outcomes measured at different time
points. GEE adjusts for auto-correlation within the same subject. We used an
unstructured correlation matrix, and thus no assumptions were made about the
correlations. The GEE procedure provides a more precise effect estimate and reduces
the error derived from multiple comparisons (Type I error). A quadratic term was
added to the linear regression models to test whether the associations between GA
and behavioural problems were curvilinear. We conducted the primary analyses in all
children, thus also including the children whose GA was assessed in the second and
third trimester. This was done to reduce the risk of potential selection bias.
Furthermore, we reran the analyses including only those children with a GA dating in
early pregnancy (N=4132), because GA dating by ultrasound is assumed to be more
accurate in early pregnancy.5
Moreover, we performed linear regression analyses for maternal ratings at 18 and 36
months separately to assess whether the quadratic association between GA at birth
and child total problems was present at both ages. We also performed the same
linear regression analyses for paternal ratings at 36 months. The results of these
analyses can be found in theSupplementary data, available at IJE online.
Both linear and quadratic analyses were rerun after exclusion of the preterm
children, to ascertain that the relationship between GA and behavioural problems
was not solely driven by the preterm children. In addition, we restricted the analyses
to the children born after 39 weeks of gestation. To check whether results were not
unduly influenced by ethnicity, we reran analyses regarding the Total Problems score
including only the indigenous Dutch children. Gender-specific estimates for the
quadratic association between GA at birth and child behavioural problems are
provided in the Supplementary Table S1, available as Supplementary
data at IJE online.
For logistic regression analyses, scales were dichotomized using the clinical cut-offs.
We further explored the nature of the association between GA and behavioural
problems with the GEE approach, and calculated the odds ratios (ORs) of clinical
problem behaviour for pre- and post-term born children. We analysed only those
scales on which >0.5% of the participants were classified as having clinical
problems; these were the ADHD, affective problems and pervasive developmental
problems scales.
Potential confounders were chosen based on the literature and effect estimate
changes. Both linear and logistic regression models were adjusted for child gender,
maternal age, education, ethnicity, psychopathology, smoking and drinking during
pregnancy, family income and age of the child at the time of assessments of the
CBCL. Maternal weight, height, parity, breastfeeding and day care did not change the
effect estimates (<5%). Maternal age, psychopathology and age of the child were
used as continuous variables. Maternal education, ethnicity, smoking, drinking and
family income were used as categorical variables in the analyses.
Several post-hoc analyses were performed, including only post-term children without
induction, without assisted extraction or no high birthweight (>4000g) to test if
effects were driven by these birth characteristics.
Not all variables were available for each participant, the mean proportion of missing
values was 5.1% and these were imputed. Variables were centred and missing data
were imputed with the mean or, for categorical variables, dummy variables were
made. The association between GA at birth and child behaviour problems of the
imputed and non-imputed data set were compared, and these associations were
similar. Therefore, we only report results of analyses with the imputed data.
For the non-response analysis, we compared maternal and child characteristics of
included participants with participants from whom we did not obtain behavioural
data. Non-responders were lower educated (14.7% primary education vs 6.3%, P<
0.001), younger (maternal age 28.1 vs 31.2 years, P<0.001), more likely to be nonDutch (62.0 vs 35.4%, P<0.001). Excluded infants had a lower birthweight (3313 vs
3431g, P<0.001) and were born after a shorter period of gestation (39.5 vs 39.8
weeks, P<0.001), compared with included infants. The proportion of children born
post-term was lower in the non-response group than in the response group (5.8 vs
6.9%, P<0.001).
Previous SectionNext Section
Results
Table 1 compares demographic and birth characteristics of 5145 children of whom
4537 (88.2%) were born at term, 382 were born post-term (7.4%) and 226 were born
preterm (4.4%).
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Table 1
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Figure 1
The unadjusted association between GA at birth and total behavioural and emotional
problem score
For continuous scores on the total problems, ADHD, affective problems scales and
pervasive developmental problems, linear regression analyses showed a curvilinear
relation between GA and behavioural problems, indicating that children with shorter
or longer gestation had higher behavioural problem scores compared with children
born at term (Table 2). After exclusion of the preterm born children, the curvilinear
relations between GA and behavioural problems remained, showing that mean
problem scores were higher in children with a longer GA [Total Problems score GA2
=0.34, 95% confidence interval (CI)= 0.140.54]. When we restricted the analyses
to the children born after 39 weeks of gestation (n=4115), we still observed a linear
association between GA at birth and total child behavioural and emotional problems
(data not shown).
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Table 2
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Table 3
Discussion
Our study demonstrated that children born post-term were more likely than their
term born peers to have emotional and behavioural problems at both 18 and 36
months after birth.
Post-term delivery and behavioural problems could be explained in several
pathways. First, a larger baby typically has a higher risk for perinatal problems.
Prolonged labour, cephalopelvic disproportion and shoulder dystocia are increased in
post-term children.2 A perinatal lack of oxygen has been associated with behavioural
problems.22 However, our results did not suggest increased fetal stress in the postterm children, as indicated by low Apgar score, low umbilical pH or meconiumstained amniotic fluid. We controlled for several birth characteristics. Moreover,
exclusion of post-term children with induction and >4000g of birth weight did not
change results. A second explanation is uteroplacental insufficiency: a non-optimal
old placenta offers fewer nutrients and less oxygen than a full term fetus
requires.1 The lack of nutrients and oxygen may predispose to abnormal fetal
development and this may lead to abnormal emotional and behavioural
development.23 In our study, we could not distinguish possible effects of
uteroplacental insufficiency from perinatal problems. Thirdly, it is possible that a
disturbance of the placental clock, which controls the length of pregnancy, is
involved. A marker of this clock is the placental secretion of corticotrophin-releasing
hormone (CRH), which is lower in women who deliver post-term than in women
delivering at term.24 CRH is the principal regulator of the maternal and fetal
hypothalamicpituitaryadrenal (HPA) axis.25 It has been suggested that placental
endocrine malfunctioning or maternal stress at critical times during fetal
development may influence the fetal HPA axis, leading to neuroendocrine
abnormalities that could increase the childs vulnerability to emotional and
behavioural problems later in life.26 Finally, the association between post-term birth
and childhood behavioural problems could be explained by underlying causes of
being born post-term. In other words, the cause for post-term could also be the
cause for having behavioural problems, for example neurodevelopmental factors
related to behavioural problems could be involved in the complex process of birth.
This is a population-based study including many post-term children. We measured
problem behaviour with the same validated instrument (CBCL/1.55) at two time
points. As ultrasound gestational dating is thought to be superior to last menstrual
period-based gestational dating,5we decided to use primarily ultrasound dating.
Eighty percent of our sample was dated with ultrasound assessment in early
pregnancy. However, some limitations must be discussed. Firstly, mothers were not
formally blinded for the GA of their children and they might perceive more
behavioural problems in post-term children. However, the notion that a post-term
birth may signal at-risk babies is largely non-existent in the medical profession and
absent in the public debate. Secondly, in the current study, we relied on the CBCL, as
it was not feasible to obtain clinical diagnoses in such a large number of children.
Moreover, these children were too young to be assessed by teachers or other
informants, thus we had to rely on parental ratings that may be biased. Moreover,
the CBCL is not a clinical instrument and cannot provide diagnoses, but addresses
continuous traits in children. However, the DSM-oriented scales provide accurate
information 17 and good reliability and validity have been reported.16
Finally, although we controlled for a large number of confounders, including maternal
smoking, psychopathology and socio-economic characteristics, residual confounding,
for example maternal malnutrition during pregnancy, cannot be ruled out.
Management of prolonged pregnancy follows two approaches: proposing induction
before 42 weeks of gestation or close monitoring of pregnancy after 41 weeks with
selective induction in case of fetal distress or a favourable Bishop score. 4 Pregnancy
and perinatal care are criticized in The Netherlands, as perinatal mortality ranks as
the third worst in Europe.27 Until mid-2008, a woman with a low-risk pregnancy at 42
weeks was referred to a gynaecologist for close monitoring only. The current revised
policy requires a referral at 41 weeks. Although the rate of post-term births went
down after introducing first trimester ultrasound dating of GA,5 post-term delivery
remains common.4
Supplementary Data
Supplementary Data are available at IJE online.
Previous SectionNext Section
Funding
The Sophia Childrens Hospital Fund (project number 553) and the WH Krger
Foundation. The first phase of the Generation R Study is made possible by financial
support from the Erasmus Medical Centre, the Erasmus University and The
Netherlands Organization for Health Research and Development (Zon MW, grant
ZonMW Geestkracht 10.000.1003).
Previous SectionNext Section
Acknowledgments
The Generation R Study is conducted by the Erasmus Medical Centre in close
collaboration with the School of Law and Faculty of Social Sciences of the Erasmus
University Rotterdam, the Municipal Health Service Rotterdam area, the Rotterdam
Homecare Foundation and the Stichting Trombosedienst & Artsenlaboratorium
Rijnmond (STAR), Rotterdam. We gratefully acknowledge the contribution of general
practitioners, hospitals, midwives and pharmacies in Rotterdam. H.E.M. checked the
references used in this article for accuracy and completeness. H.T. will act as
guarantor for the article. Someone with an excellent mastery of the English language
has carefully edited the article. This article represents original material and has not
been published previously in whole or in part. In addition, no similar paper is in press
or under review elsewhere.
Conflict of interest: F.C.V. is author and head of the Department of Child and
Adolescent Psychiatry at Erasmus MC, which publishes the Achenbach System of
Empirically Based Assessment (ASEBA) and from which he receives remuneration. All
other authors report no conflicts of interest.
KEY MESSAGES
Children born post-term were twice as likely as their term-born peers to have
ADHD in early childhood.
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http://ije.oxfordjournals.org/content/early/2012/04/11/ije.dys043.full
Senat k , Loc Sentilhes l , Aurelie Serry m , Norbert Winer n , Hlne Grandjean b , Eric Verspyck o and Damien
Subtil p
European Journal of Obstetrics & Gynecology and Reproductive Biology, 1, 169, pages 10 - 16
Abstract
The duration of pregnancy varies between 40+0 and 41+3 weeks. Conventionally, and essentially arbitrarily, a
pregnancy is considered to be prolonged after 41+0 weeks, but the infant is not considered post-term until
42+0 weeks (Professional consensus). A term birth thus occurs during the period from 37+0 to 41+6 weeks.
In France, prolonged pregnancies (41+0weeks) involve 1520% of pregnant women, and post-term pregnancies
(42+0 weeks) approximately 1%. The frequency of post-term pregnancies is very heterogeneous: in Europe and
the United States, it ranges from 0.5% to 10% according to country.
In prolonged pregnancies, the cesarean section rateespecially the emergency cesarean rateis multiplied by
approximately 1.5 (grade B). From 3706 to 4306 weeks, the risk of perinatal mortality increases regularly, from
0.7 to 5.8.
Meconium aspiration syndrome is responsible for substantial morbidity and mortality, and its incidence increases
regularly between 38+0 and 42+6 weeks, from 0.24 to 1.42 (grade B). Similarly, the risks of neonatal acidosis
(grade B), 5-min Apgar scores less than 7 (grade B) and admissions to neonatal intensive care (grade B)
increase progressively between 38+0 and 42+6 weeks. These risks appear to double for post-term growthrestricted newborns (grade C).
Ultrasound dating of the pregnancy makes it possible to reduce the risk that it will be incorrectly considered
prolonged and that labor will therefore be induced unnecessarily. To harmonize practices, if the crown-rump
length (CRL) is correctly measured (this measurement should be taken between 11+0 and 13+6 weeks, when CRL
should measure from 45 to 84mm), ultrasound dating based on it should be used to determine the official date
pregnancy began, regardless of its difference from the date assumed by the patient or estimated based on the
date of the last menstrual period. This rule does not apply to pregnancies by IVF, for which the date pregnancy
began is defined by the date of oocyte retrieval (Professional consensus).
From 3706 to 4306 weeks, the risk of perinatal mortality increases regularly and there is no threshold at which a
clear increase in perinatal mortality becomes visible. Fetal monitoring by cardiotocography (CTG) that begins at
41+0 weeks would cover approximately 20% of women and reduce perinatal morbidity compared with monitoring
that begins at 42+0 weeks (grade C). The frequency recommended for this monitoring ranges between two and
three times a week (Professional consensus).
For ultrasonography assessment, measurement of the largest fluid pocket is recommended, because
measurement of the amniotic fluid index (that is, the sum of the four quadrants) is accompanied by more
diagnoses of oligohydramnios, inductions of labor, and cesareans for fetal distress without any improvement in
neonatal prognosis (grade A). The practice of assessing the Manning biophysical score increases the number of
diagnoses of oligohydramnios and fetal heart rage (FHR) abnormalities and generates an increase in the rates of
inductions and cesareans without improving neonatal prognosis. The use of this biophysical score in monitoring
prolonged pregnancies is therefore not recommended (grade B).
In the absence of a specific disorder, induction of labor can be proposed in patients between 41+0 and 42+6 weeks
(grade B). Nonetheless, the choice of prolongation beyond above 42+0 weeks appears to involve an increase in
fetal risk, which must be explained to the patient and balanced against the potential disadvantages of induction
(Professional consensus).
Stripping the membranes can reduce the duration of pregnancy by increasing the number of patients going into
labor spontaneously during the week afterward (grade B). Compared to an expectant approach, it does not
increase the cesarean section rate (grade A). It reduces recourse to induction by 41% at 41+0 weeks and by 72%
at 42+0 weeks (grade B), without increasing the risk of either membrane rupture or maternal or neonatal infection
(grade B).
Used as a tampon or vaginal gel, prostaglandins E2 (PGE2) are an effective method of inducing labor (grade A).
They can be used to induce labor successfully, regardless of cervical ripeness (grade A). If misoprostol is chosen,
the lowest dose is to be preferred, starting with a vaginal dose of 25g every 36h (grade A). For misoprostol,
more powerful studies remain necessary for better defining the doses, routes of administration, tolerance and
indications. Misoprostol at any dose is contraindicated in women with uterine scars (grade B). Placement of an
intracervical Foley catheter is an effective mechanical means of inducing labor, with less uterine hyperstimulation
than prostaglandins and no increase in the cesarean section rate (grade A). Nonetheless, as the risk of infection
might be increased, this technique requires more robust evaluation before entering general practice (grade B).
In cases of meconium-stained amniotic fluid, pharyngeal aspiration before delivery of the shoulders is not
recommended (grade A). The team managing a post-term newborn with meconium-stained amniotic fluid at birth
must know how to perform intubation and, if the intubation is not helpful, endotracheal aspiration (grade C) and
ventilation with a mask. Routine endotracheal intubation of a vigorous newborn is not recommended (grade A).
For ultrasonography assessment, measurement of the largest fluid pocket is recommended, because
measurement of the amniotic fluid index (that is, the sum of the four quadrants) is accompanied by more
diagnoses of oligohydramnios, inductions of labor, and cesarean sections for fetal distress without any
improvement in neonatal prognosis (grade A).
In view of the risk of oligohydramnios and of increased morbidity and mortality after 41+0 weeks, it seems
reasonable to suggest prenatal ultrasound monitoring of the quantity of amniotic fluid (measurement of the
largest amniotic fluid pocket) starting at 41+0 weeks and thereafter twice a week (Professional consensus). In
cases of oligohydramnios, defined as less than 2cm in the largest pocket, induction can be envisioned
(Professional consensus). In the absence of induction, monitoring must be reinforced (Professional consensus).
membranes should not be performed during a routine examination without advance information and consent
(Professional consensus).
References
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Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:701-702
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[4] Clinical Practice Obstetrics Committee, Maternal Fetal Medicine Committee, M. Delaney, et
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Canada. 2008;30:800-823
[5] G. Mandruzzalo, Z. Alfirevic, F. Chervenak, et al. Guidelines for the management of postterm
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[6] C. Le Ray, O. Anselem. Definitions of expected date of delivery and postterm delivery. Journal de
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[7] A. Chantry. Epidemiology of prolonged pregnancy: incidence and maternal morbidity. Journal de
Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:709-716
[8] A. Chantry, E. Lopez. Fetal and neonatal complications related to prolonged pregnancy. Journal de
Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:717-725
[9] L.J. Salomon. How to date pregnancy?. Journal de Gynecologie, Obstetrique et Biologie de la
Reproduction. 2011;40:726-733
[10] J.B. Haumonte, C. dErcole. Prolonged pregnancy: when should surveillance be started and what
should be the frequency?. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:734-746
[11] M.P. Debord. To evaluate the role of fetal movement counting and amnioscopy in the management
of prolonged pregnancies. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:767-773
[12] F. Coatleven. Place of fetal heart rate monitoring and its computerized analysis during the
surveillance of prolonged pregnancy. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction.
2011;40:774-784
[13] M.V. Senat. Management of postterm pregnancies: the role for AFI, biophysical score and
Doppler. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 2011;40:785-795
[14] L. Sentilhes, P.E. Bouet, M. Mezzadri, et al. Assessment of the benefit-harm balance depending on
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PDF Format
use of the work groups recommended new gestational age designations by all clinicians,
researchers, and public health officials to facilitate data reporting, delivery of quality health care,
and clinical research.
Opinion
Gestation in singleton pregnancies lasts an average of 40 weeks (280 days) from the first day of
the last menstrual period to the estimated date of delivery. In the past, the period from 3 weeks
before until 2 weeks after the estimated date of delivery was considered term (1), with the
expectation that neonatal outcomes from deliveries in this interval were uniform and good.
Increasingly, however, research has identified that neonatal outcomes, especially respiratory
morbidity, vary depending on the timing of delivery even within this 5-week gestational age range.
The frequency of adverse neonatal outcomes is lowest among uncomplicated pregnancies
delivered between 39 0/7 weeks of gestation and 40 6/7 weeks of gestation (2, 3). For this reason,
quality improvement projects have focused, for example, on eliminating nonmedically indicated
deliveries at less than 39 0/7 weeks of gestation (4).
In order to facilitate data reporting, delivery of quality health care, and clinical research, it is
important that all clinicians, researchers, and public health officials use both uniform labels when
describing deliveries in this period and a uniform approach to determining gestational age. To
address the lack of uniformity in neonatal outcomes between 37 0/7 weeks of gestation and 42 0/7
weeks of gestation, a work group was convened in late 2012 to determine whether term pregnancy
should be redefined (5). The work group included representatives from the Eunice Kennedy
Shriver National Institute of Child Health and Human Development, the American College of
Obstetricians and Gynecologists (the College), the Society for Maternal-Fetal Medicine (SMFM), and
other professional societies and stakeholder organizations. The work group recommended that the
label term be replaced by the designations early term, full term, late term, and postterm to more
accurately describe deliveries occurring at or beyond 37 0/7 weeks of gestation (Box 1). The group
recommended that the use of the label term to describe all deliveries between 37 0/7 weeks of
gestation and 41 6/7 weeks of gestation should be discouraged. Details of the evidence and
rationale that are the foundation of these recommendations can be found in published summaries
of this conference (5).
The College and SMFM endorse and encourage the uniform use of the work groups recommended
new gestational age designations by all clinicians, researchers, and public health officials to
facilitate data reporting, delivery of quality health care, and clinical research.
Uniform definitions of term are predicated on a uniform method of determining gestational age.
The work group provided a method for determination of gestational age (5) that, like other similar
methods (6), focused on a hierarchy of clinical and ultrasonographic criteria. Individual methods
may differ in the details of when and how ultrasonographic biometry should be used to change
estimated date of delivery based on last menstrual period; however, it is not the purpose of this
document to establish the priority of one method over another. The College and SMFM are working
with other expert groups to establish evidence-based consensus on criteria for determining
gestational age.
References
1.
2.
3.
4.
5.
6.
Copyright November 2013 by the American College of Obstetricians and Gynecologists, 409 12th
Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.
ISSN 1074-861X
Definition of term pregnancy. Committee Opinion No. 579. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2013;122:113940.
Objectives. This study assessed the efficacy of the two outpatient processes of singledose 50 g oral misoprostol (OM) and membrane sweeping (MS) on the outcome of
labour induction and the possibility of reducing the need for hospital admission for
cervical ripening/labour induction in uncomplicated post-term singleton pregnancies at
a tertiary health institution in south-western Nigeria.
Methods. A total of 100 patients were equally randomised into the two groups between
April 2007 and March 2010. Primary outcome measures were delivery within 48 hours
after the start of induction and route of delivery. Secondary outcome measures were
time interval from induction to onset of labour (latency period), time interval from start
of induction to delivery (duration of labour), need for oxytocin augmentation, labour
complications, Apgar scores at 1 and 5 minutes, and need for neonatal intensive care
unit (NICU) admission.
Results. Both groups were similar at the baseline with regard to age, parity and days
beyond 40 weeks gestation. There was a significantly shorter induction to onset of
labour (latency) interval in the OM group, with a mean of 17.0 hours compared with
31.9 hours in the MS group (p=0.005), with 82.0% of the patients in the OM group in
spontaneous labour within the latency period of 18 hours as opposed to 32.6% of the
MS group (p<0.005). Forty-two patients in the OM group and 40 in the MS group had a
vaginal delivery (84.0% v. 87.0%, p=0.361), with 12 and 20 patients in the OM and MS
groups, respectively, requiring oxytocin augmentation (p=0.023). The duration of
labour was significantly shorter in the OM group, in which 78.6% of those who had a
vaginal delivery achieved it within 9 hours, compared with 57.5% in the MS group
(p=0.036). Overall, neonatal outcomes and need for NICU admission were similar and
comparable in the two groups. On a preference scale, 43% of the women in the MS
group felt positive about the intervention, compared with 92% of the women in the OM
group.
Conclusion. The study demonstrated a shorter latency period, less need for oxytocin
augmentation and shorter duration of labour in patients who received OM. The two
induction agents were similar with regard to neonatal outcomes and need for NICU
admission. Both showed good safety profiles for outpatient care, although further
assessment of the safety profile with larger studies will be needed. More patients felt
positive about the intervention in the OM group than in the MS group.
Post-term pregnancy is fairly common in obstetric practice and is the most common
indication for induction of labour.1 , 2 , 3 , 4 Recent studies have shown that the risks to
the fetus 5 , 6 and to the mother 7 , 8 of continuing pregnancy beyond the estimated
date of delivery are greater than originally thought, and induction of labour remains an
accepted means of achieving vaginal delivery. In some cases the status of the cervix is
unfavourable for labour induction, the success of which depends to a large extent on
the consistency, compliance and configuration of the cervix. 9 Various methods of
cervical ripening, from membrane sweeping (MS) and use of a transcervical Foley
catheter to administration of prostaglandins (PG) and prostaglandin E1 (PGE1)
analogue, are therefore used.
MS involves digital separation of the fetal membranes from the lower segment of the
uterus. It is an established method of promoting the onset of labour without hospital
admission, and is regularly applied to prevent pregnancies extending beyond
term. 10 , 11 This method causes an increase in local PG production, 12 , 13 which
results in ripening of the cervix and ultimately brings about spontaneous onset of
labour. The results of trials on the effectiveness of MS have been
inconsistent, 3 , 8 , 11 possibly owing to methodological differences between studies. A
Cochrane review suggested that routine use of MS between 38 and 40 weeks does not
seem to produce clinically important benefits; 11 however, it may be beneficial in
women with post-term pregnancies. 14 , 15
Misoprostol, a PGE1 analogue, has been reported to be an effective and affordable
cervical ripening and medical induction agent. It can be used intravaginally or orally and
has excellent shelf-life. These factors are immensely advantageous in low-resource
tropical countries. 2 , 4 However, the processes of cervical ripening and labour induction
require admission to hospital, resulting in additional costs in terms of both human and
material resources. Any safe and effective interventions that also cut costs are
therefore desirable. This study explored the comparative efficacy and safety of the two
outpatient techniques of single-dose 50 g oral misoprostol (OM) and MS on the
outcome of labour induction and their effects on reducing the need for hospital
admission for cervical ripening/labour induction in uncomplicated post-term singleton
pregnancies.
Methods
This study was a prospective, randomised controlled trial of a single dose of 50 g OM
and MS in uncomplicated singleton post-term pregnancies. All patients recruited had
had early ultrasound dating of their pregnancy, which was correlated with the expected
delivery date to exclude wrong dates. The study was conducted between April 2007 and
March 2010 at Ladoke Akintola University of Technology Teaching Hospital, Osogbo,
Nigeria. Patients with singleton post-term pregnancies were recruited after giving
informed consent. One hundred sealed opaque envelopes containing papers marked OM
or MS (50 each) were placed in a box, thoroughly mixed and then numerically labelled.
Computer-generated random numbers were used for patient allocation. Patients were
allocated sequential numbers in order of recruitment, and the correspondingly
numbered envelope was opened for randomisation. The institutional ethical review
committee approved the study. Inclusion criteria were a singleton live fetus, post-term
pregnancy from 40 weeks and 1 day to 40 weeks and 9 days, intact fetal membranes,
Bishops score 5 and cephalic presentation. Exclusion criteria were post-term
pregnancies of 40 weeks and 10 days, multiple pregnancies, grand multiparity,
cephalopelvic disproportion, previous caesarean section or a uterine scar, fetal
malpresentation, fetal distress, placenta praevia, antepartum haemorrhage, premature
rupture of the membranes and medical disorders.
Study groups
One hundred patients, randomised to 50 in each group, were studied. The OM group
received a single 50 g misoprostol tablet orally on an outpatient basis, and the MS
group had MS once only at the antenatal clinic. Patients with unyielding cervices
preventing access into the cervical canal were termed failed MS. All patients in both
groups who did not go into spontaneous labour after 48 hours were categorised as
failed labour induction and together with the women with post-term pregnancies of
40 weeks and 10 days managed according to our departmental protocol of cervical
ripening and labour induction (transcervical Foley catheter or intravaginal misoprostol)
to ensure delivery before 42 weeks gestation.
To eliminate bias, attending obstetricians in the labour ward were blinded to the labourinducing agents used in the study groups. Primary outcome measures were delivery
within 48 hours after the start of induction and route of delivery. Secondary outcome
measures were time interval from the start of induction to onset of labour (latency
period), time interval from the start of induction to delivery (duration of labour), need
for oxytocin augmentation, labour complications, Apgar scores at 1 and 5 minutes, and
need for neonatal intensive care unit (NICU) admission.
Data were entered onto a pre-designed sheet and analysed with SPSS version 17. Mean
( standard deviation (SD)), independent t-test, Pearsons chi-square (with Yates
corrections as appropriate), confidence intervals (CIs) and relative risk (RR) were
determined as necessary. The level of significance was set at 0.05.
Results
A total of 100 patients (50 in each group) were recruited for the study; 4 in the MS
group were categorised as failed MS. At baseline the two groups were similar with
regard to mean age, parity and days beyond 40 weeks gestation (Table 1). Table 2
shows that the latency period was significantly shorter in the OM group than in the MS
group, with a mean of 17.0 hours (CI 11.8 - 22.1) as opposed to 31.9 hours (CI 24.7 39.0) in the MS group (p=0.005). Eighty-two per cent of the patients in the OM group
went into labour spontaneously within the latency period of 18 hours, as opposed to
32.6% in the MS group (p<0.005). Two patients in the OM group and 1 in the MS group
went beyond the 48 hours time limit and were categorised as failed induction, but
subsequently had a vaginal delivery after oxytocin augmentation of labour.
OM group ( N =50)
MS group ( N =50)
p -value
26.30 (4.9)
25.38 (5.1)
0.830
1.70 (0.8)
1.32 (0.9)
Nulliparous, n (%)
3 (6.0)
10 (20.0)
Multiparous, n (%)
47 (94.0)
40 (80.0)
5.26 (1.6)
5.00 (1.7)
0.071
0.290
mean (SD)
OM group ( N =50)
n (%)
MS group ( N =46)
n (%)
p -value
<6
5 (10.0)
4 (8.7)
<0.005
>6 - 12
18 (36.0)
4 (8.7)
>12 - 18
18 (36.0)
7 (15.2)
>18 - 24
4 (8.0)
13 (28.3)
>24 - 48
3 (6.0)
17 (37.0)
>48
2 (4.0)
1 (2.2)
Forty-two patients in the OM group and 40 in the MS group had a vaginal delivery
(84.0% v. 87.0%, p=0.361), with 12 and 20 patients, respectively, requiring oxytocin
augmentation (p=0.023). Of the caesarean sections (8 in the OM group v. 6 in the MS
group), 5 in the OM group were necessitated by presumed fetal distress, compared with
4 in the MS group (Table 3). The duration of labour was significantly shorter in the OM
group, with 33/42 patients (78.6%) who had a vaginal delivery achieving it within 9
hours, compared with 23/40 (57.5%) in the MS group (Table 4).
OM group ( N =50)
n (%)
MS group ( N =46)
n (%)
Oxytocin augmentation
p -value (CI)
Yes
12 (24.0)
20 (43.5)
No
38 (76.0)
26 (56.5)
Mode of delivery
Vaginal
42 (84.0)
40 (87.0)
Caesarean section
8 (16.0)
6 (13.0)
OM group ( N =42)
MS group ( N =40)
n (%)
n (%)
<6
1 (2.4)
4 (10.0)
>6 - 9
32 (76.2)
19 (47.5)
>9 - 10
8 (19.0)
12 (30.0)
>10 - 12
1 (2.4)
5 (12.5)
p -value
0.036
Overall, neonatal outcomes were similar and comparable in the two groups, with more
babies in the OM group (6/50) than in the MS group (3/46) having moderate asphyxia
at the first minute after birth. However, this was statistically insignificant. NICU
admission rates were similar for the two groups. On a preference scale, 43% of the
women in the MS group felt positive about the intervention, compared with 92% of the
women in OM group who said that they would agree to use of the drug in another postterm pregnancy.
OM group
( N =50)
MS group
( N =46)
p -value (CI)
3 123 (328)
3 089 (302)
7.7 (1.0)
7.4 (0.7)
6 (12.0)
3 (6.5)
0.358
9.5 (0.6)
9.478 (0.4)
2 (4.0)
2 (4.4)
0.930
Discussion
This study randomised 100 patients, with established gestations beyond 40 weeks but
less than 40 weeks and 10 days, into two groups receiving a single-dose 50 g OM
tablet or single MS on an outpatient basis. The intention was to compare the efficacy of
these two methods for induction of labour, evaluate their possible impact on the
number of post-term women requiring hospital admission for induction of labour at our
institution, and compare fetomaternal safety profiles of the two methods. Various
Conclusion
This study showed a shorter latency period, less need for oxytocin augmentation and a
shorter duration of labour in patients given single-dose OM compared with MS on an
outpatient basis. The two induction agents were similar with regard to neonatal
outcomes and need for NICU admission, but differences in outcomes cannot be
excluded owing to the small numbers studied. Patient preference for the intervention
was higher in the OM group than in the MS group.
Conflict of interest. We declare that we have no conflict of interest; no funding/grant
was received for this study and there was no commercial relationship. We have full
control of all primary data and agree to allow SAJOG to review our data if requested.
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