Post term pregnancy

INTRODUCTION The timely onset of labor and delivery is an important

determinant of perinatal outcome. Both preterm and postterm births are associated with higher
rates of perinatal morbidity and mortality than pregnancies delivering at term.
DEFINITION Postterm pregnancy refers to a pregnancy that has 42 0/7ths weeks of gestation
or 294 days from the first day of the last menstrual period [ 1 ]. Accurate pregnancy dating is
critical to the diagnosis.
PREVALENCE In the United States, approximately 27 percent of pregnancies deliver in the
40 th and 41 st week and 5.5 percent deliver at 42 weeks [ 2 ]. A study of postterm birth rates in
13 European countries observed a wide range across the continent: from 0.4 percent in Austria
and Belgium to 8.1 percent in Denmark [ 3 ]. The authors attributed the variation to differences
in prenatal assessment of gestational age and obstetric practices.
The prevalence of postterm pregnancy in a population is affected by several factors. One of the
most important factors is whether routine early ultrasound assessment of gestational age is
performed. Among pregnancies dated by first trimester ultrasound examination, the prevalence
of delivery 42 weeks is about 2 percent (versus 6 to 12 percent by last menstrual period [LMP])
[ 4-7 ] and the prevalence of delivery 41 weeks ranges from 5 to 11 percent (versus 13 to 22
percent by LMP) [ 6,8-10 ]. In a meta-analysis that compared the rate of labor induction for
postterm pregnancy in women who underwent sonographic estimation of their delivery date
(EDD) in early pregnancy with the rate in women whose EDD was calculated from their LMP,
early routine ultrasound examination reduced the rate of intervention for postterm pregnancy
(OR 0.68, 95% CI 0.57-0.82) [ 4 ].
Other factors that affect the prevalence of postterm pregnancy in a population include the rate of
spontaneous preterm birth, the prevalence of primigravid women (who are more likely to deliver
postterm), and the prevalence of women with pregnancy complications (who are less likely to
deliver postterm). Local practice patterns, such as the rate of scheduled cesarean delivery and
elective labor induction, will also affect the prevalence of postterm birth.
ETIOLOGY AND RISK FACTORS The majority of postterm pregnancies have no known
etiology. One third to one half of the variation in postterm birth in a population can be attributed
to maternal or fetal genetic influence on the initiation of parturition [ 11 ]. In rare cases, postterm
pregnancy can be attributed to known defects in fetal production of hormones involved in
parturition. In the past, anencephaly was a cause of postterm pregnancy in the absence of
polyhydramnios, but these pregnancies are now routinely detected antepartum and terminated or
induced. X-linked ichthyosis (MIM 308100), which is associated with placental sulfatase
deficiency, is another rare cause of postterm pregnancy [ 12 ].
Women at highest risk of postterm pregnancy are those with a previous postterm pregnancy.
After one postterm pregnancy, the risk of a second postterm birth is increased two- to three-fold;

the risk of recurrence is quadrupled after two prior postterm pregnancies [ 13-15 ]. Additional,
more modest risk factors (RR <2) include [ 11,13,14,16-21 ]:

Nulliparity

Male fetus

Maternal obesity

Older maternal age

Maternal or paternal personal history of postterm birth

Maternal race/ethnicity (African-American women, Latina, and Asian women are at

lower risk than Caucasians)

MORBIDITY AND MORTALITY Postterm pregnancy is associated with fetal, neonatal, and
maternal risks [ 22-26 ].
Fetal and neonatal risks Postterm fetuses tend to be larger than term fetuses, with a higher
incidence of macrosomia (4500 g) (2.5 to 10 percent versus 0.8 to 1 percent at term) [ 27-29 ].
Complications of macrosomia include prolonged labor, cephalopelvic disproportion, and
shoulder dystocia, all of which increase the risk of birth injury. (See "Fetal macrosomia" and
"Timing and route of delivery in pregnancies at risk of shoulder dystocia" .)
In contrast, up to 20 percent of postterm fetuses have "fetal dysmaturity (postmaturity)
syndrome," a term used to describe infants with characteristics of chronic intrauterine
malnutrition [ 30-32 ]. These fetuses are at increased risk of umbilical cord compression due to
oligohydramnios, and nonreassuring antepartum or intrapartum fetal heart rate patterns due to
placental insufficiency or cord compression. Meconium passage is common and may be related
to physiological maturation of the gut or fetal hypoxia. Neonates have a long thin body, long
nails, and are small for gestational age. Their skin is dry (vernix caseosa is decreased or absent),
meconium stained, parchment-like, and peeling; it appears loose, especially over the thighs and
buttocks, and has prominent creases; lanugo hair is sparse or absent, while scalp hair is
increased. These fetuses/neonates are at risk for the short- and long-term morbidity typically seen
in intrauterine growth restriction/small for gestational age infants. (See "Postterm infant" and
"Fetal growth restriction: Evaluation and management", section on 'Outcome' and "Small for
gestational age infant" .)
Perinatal mortality increases as pregnancy extends beyond 39 to 40 weeks of gestation due to
increases in both non-anomalous stillbirths and early neonatal deaths [ 33-36 ]. Intrauterine
infection, placental insufficiency and cord compression leading to fetal hypoxia, asphyxia, and
meconium aspiration are thought to contribute to the excess perinatal deaths [ 37,38 ]. The
perinatal mortality rate at 42 weeks of gestation is twice the rate at term, increasing four-fold at
43 weeks, and five- to seven-fold at 44 weeks [ 25,38-41 ]. Neonates born at 41 weeks of
gestation experience one-third greater neonatal mortality than term neonates born at 38 to 40

weeks of gestation [ 33 ]. However, the absolute risk of fetal or neonatal death is low. (See
'Expectant management' below and "Postterm infant", section on 'Perinatal mortality' .)
The long-term effects of postterm birth are unclear. Studies on long-term outcomes for children
born postterm are reviewed separately. (See "Postterm infant", section on 'Long-term outcome' .)
Maternal risks Maternal risks of postterm pregnancy include an increased frequency of labor
abnormalities and sequelae of labor induction and fetal macrosomia. These sequelae include
failed induction, third and fourth degree perineal lacerations, and postpartum hemorrhage [ 42-44
].
MANAGEMENT The following discussion refers to the singleton, cephalic fetus of an
otherwise uncomplicated pregnancy that reaches 41 weeks of gestation. Multiple gestations, noncephalic presentations, and complicated pregnancies are generally delivered before 41 weeks.
We favor induction of well-dated postterm pregnancies at or shortly after 41 0/7ths weeks of
gestation, irrespective of cervical status. The alternative is expectant management with ongoing
fetal assessment with intervention if fetal assessment is not reassuring or spontaneous labor does
not occur by a predefined gestational age. Both of these approaches are associated with low
complication rates in the low-risk postterm gravida [ 45 ].
Induction Induction of postterm pregnancy rather than expectant management with fetal
monitoring is supported by several lines of evidence:

Lower perinatal mortality and morbidity

In a 2012 meta-analysis of randomized trials comparing a policy of labor induction to a

policy of awaiting spontaneous onset of labor at 39 to 42 weeks:
Routine labor induction at >41 weeks of gestation compared with expectant management
resulted in lower perinatal mortality (1/2814 versus 9/2785; RR 0.30, 95% CI 0.09-0.99;
10 trials) and a lower rate of meconium aspiration syndrome (RR 0.61, 0.40-0.92; 5 trials,
1395 patients) [ 46 ]. For induction at 41 0/7ths , the risk of perinatal mortality was also
lower than with expectant management, but did not achieve statistical significance (0/501
versus 2/497; RR 0. 33, 95% CI 0.03-3.17; 4 trials, 998 patients).

When fetal mortality is based on the number of fetal deaths per 1000 ongoing
pregnancies (rather than per 1000 deliveries), an analysis of fetal versus neonatal
mortality rates concluded the rate of fetal demise was significantly higher than the rate of
neonatal death at any gestational age 40 3/7ths weeks of gestation [ 47 ].

No increase in or a reduction in cesarean delivery

Meta-analyses have reported that routine induction at >41 weeks results in no increase in
the risk of cesarean delivery compared with expectant management (RR 0.91, 95% CI
0.82-1.00; 12 trials, 5994 patients) [ 46 ] or a decrease in the cesarean birth rate (pooled

cesarean delivery rate with induction at 41 weeks: 17.5 versus 20.1 percent; P = 0.04; 8
trials, 6054 women) [ 48 ].

Patient satisfaction

A survey of women at 41 weeks of gestation reported that 74 percent preferred induction

to expectant management [ 49 ].

We agree with guidelines that suggest routine induction between 41 0/7ths and 42 0/7ths weeks of
gestation rather than expectant management and monitoring as intervention at this time reduces
perinatal mortality without increasing perinatal morbidity or cesarean delivery rates [ 8,50 ]. The
exact timing during this week should take into account clinician and patient preferences and local
circumstances. We favor induction of well-dated postterm pregnancies at or shortly after 41 0/7ths
weeks of gestation.
However, this approach has not been universally accepted [ 51 ], in part because of the low
absolute rates of fetal and neonatal death: at 41 0/7ths weeks, 527 inductions would be necessary to
prevent one perinatal death; at 43 weeks, 195 inductions would be necessary to prevent one
perinatal death [ 52 ].
We utilize cervical ripening agents in women with unfavorable cervices. In women wishing to
avoid pharmacologic agents for cervical ripening and induction, membrane sweeping (also called
stripping) can be performed if the cervix is sufficiently dilated, and reduces the proportion of
patients who remain undelivered at 42 weeks. This was illustrated in a trial that randomly
assigned 742 low-risk women at 41 weeks of gestation to membrane sweeping every 48 hours or
expectant management [ 53 ]. At baseline, the Bishop score was <6 in 78 percent of women in
the intervention group; the expectant management group did not undergo cervical examination.
Serial membrane sweeping resulted in fewer pregnancies reaching 42 0/7ths weeks (23 versus 41
percent without membrane sweeping, RR 0.57 95% CI 0.46-0.71, number needed to treat 6). The
optimum time to initiate membrane sweeping and the frequency (once versus on multiple days)
has not been studied. Beginning anytime after 39 weeks of gestation is reasonable. (See
"Techniques for ripening the unfavorable cervix prior to induction" .)
Expectant management Postterm pregnancy is a universally accepted indication for antenatal
fetal monitoring because the risk of antepartum fetal demise increases with advancing gestational
age. In large studies from the United Kingdom, the risk of antepartum fetal demise was [ 54 ]:

40 to 41 weeks: 0.86 to 1.08 per 1000 ongoing pregnancies

41 to 42 weeks: 1.2 to 1.27 per 1000 ongoing pregnancies

42 to 43 weeks: 1.3 to 1.9 per 1000 ongoing pregnancies

>43 weeks: 1.58 to 6.3 per 1000 ongoing pregnancies

However, the efficacy of antenatal fetal assessment for preventing unexplained fetal demise in
postterm fetuses has not been validated by appropriately sized and placebo-controlled
randomized trials, and probably never will be evaluated in this way because of ethical and
medicolegal concerns of assigning some pregnancies to an unmonitored group. One small trial
that compared two methods of fetal assessment has been performed, and did not find a difference
in neonatal outcome between groups [ 55 ].
The optimal type and frequency of fetal testing, and the gestational age for beginning
monitoring, have not been determined. We suggest monitoring fetal well-being by the nonstress
testing with amniotic fluid volume assessment or by the biophysical profile (BPP); neither
method has been proven to be superior. Doppler ultrasonography of the umbilical artery has no
proven benefit in monitoring the postterm fetus and is not recommended for this indication [
56,57 ]. Case control studies support initiating antepartum fetal surveillance between 41 0/7ths and
42 0/7ths weeks of gestation (287 to 294 days) [ 58,59 ]. We suggest twice weekly testing beginning
at 41 0/7ths weeks or shortly thereafter. (See "Overview of fetal assessment", section on 'Antenatal
testing methods' .)
Induction is indicated for development of any of the usual obstetrical indications, including
evidence of oligohydramnios [ 60,61 ]. Adverse pregnancy outcomes (nonreassuring fetal heart
rate tracing, neonatal intensive care unit admission, low Apgar) are more likely when
oligohydramnios is present [ 60-65 ]. Frequent assessment is important because amniotic fluid
can become severely reduced within 24 to 48 hours [ 66 ]. (See "Oligohydramnios" .)