Chapter 36
Prolonged and
Postterm Pregnancy
ROXANE RAMPERSAD and GEORGE A. MACONES
Definition 796 Postmaturity 799
Incidence 796 Meconium 799
Etiology 797 Maternal Complications
Diagnosis 797 Management 799
Perinatal Morbidity and Mortality 797 Antenatal Surveillance 799
Oligohydramnios 798 Expectant Management Versus Induction
Fetal Growth 799 of Labor 800
KEY ABBREVIATIONS
American College of Obstetricians and ACOG
Gynecologists (ACOG), International Federation of Gynecology and Obstet-
Amniotic fluid index AFI
Confidence interval CI
Estimated date of delivery EDD
International Federation of Gynecology FIGO
and Obstetrics cutoff has been used for several decades and was first suggested
Last menstrual period LMP
Odds ratio OR
Perinatal mortality rate PMR
Randomized controlled trial RCT
Relative risk RR
Society for Maternal-Fetal Medicine SMFM
World Health Organization WHO
Obstetricians have long recognized the detrimental effects of
preterm delivery, but for the last century, there has also been
concern for pregnancies that have gone beyond the normal
period of gestation. Early descriptions from prolonged pregnan-
cies described a large fetus and resulted in a difficult delivery
with an increased risk of stillbirth.1 Later descriptions suggested
that a postterm fetus not only could be large but also small for
gestational age.2 These concerns led some to adopt a practice of
inducing labor to avoid complications in prolonged pregnancies.
This practice was variable, and somewhat controversial, because
the upper limit of pregnancy was not well defined and the risks
were inconsistent. More recent studies show a small but sig-
nificantly increased risk in perinatal morbidity and mortality
in postterm pregnancies, and hence, postterm pregnancy is
one of the most common reasons for induction of labor in
the United States.
796
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
Labor Induction 800
Long-Term Neonatal
799 Outcomes 800
Multiple Gestation 801
DEFINITION
The American College of Obstetricians and Gynecologists
rics (FIGO), and the World Health Organization (WHO) have
defined a postterm pregnancy as a gestation that has com-
pleted or gone beyond 42, weeks or 294 days, from the first
day of the last menstrual period (LMP).3-5 This gestational age
based on early studies that reported an increased risk of fetal
death at 42 weeks and beyond.6 However, in view of more recent
perinatal mortality data derived from accurately dated pregnan-
cies, it would be reasonable to conclude that the gestational
age that warrants clinical concern should be 41 weeks.
Many terms have been used in the literature, including post-
mature, postdates, prolonged, and postterm. These terms have been
used with varying definitions, which has led to some confusion
regarding proper terminology. Recently ACOG and the Society
for Maternal-Fetal Medicine (SMFM) has endorsed the use of
new terminology recommended by the Defining Term Preg-
nancy Workgroup to decrease confusion among physicians,
patients, and researchers and to designate gestational ages at
higher risk.7-8 Pregnancies are now designated to be early term
if they are 370/7 weeks through 386/7 weeks. Full term is defined
at 390/7 weeks through 406/7 weeks. Pregnancies are to be des-
ignated as late term if they are 410/7 weeks through 416/7
weeks. Postterm will continue to be defined as 420/7 weeks
and beyond.
INCIDENCE
According to the vital statistics reported by the Centers
for Disease Control and Prevention (CDC), the overall inci-
dence of postterm pregnancies was 5.6% in 2012 and has
not significantly changed compared with previous years.9
Other published studies have shown varying frequency of post-
term pregnancies depending on the population studied. The
 Chapter 36 Prolonged and Postterm Pregnancy
incidence of prolonged pregnancies in European countries also
varies widely, with rates as low as 0.4% in Austria and as high
as 7% in Denmark and Sweden.10 These differences are most
likely explained by different approaches for managing pregnan-
cies beyond the estimated date of delivery (EDD) and different
criteria for gestational age dating.
ETIOLOGY
The etiology of the majority of pregnancies that are late term
or postterm is unknown, but some pregnancies may be
defined as late term or postterm as the result of an error in
dating. It is common practice to assign an EDD based on the
LMP. This practice has been proven by several studies to be
unreliable and may have led to the incorrect classification of a
pregnancy as late term or postterm.11
Understanding the events that lead to parturition in human
gestation may help to provide clues to the pathophysiology in
prolonged pregnancies. Parturition is the result of a complex
interplay among the mother, fetus, and placenta.12 The mech-
anism in human gestation is unknown but may be similar to
that of other mammals. In sheep, the hypothalamic-pituitary-
adrenal (HPA) axis is important in the timing of birth. The
release of corticotropin-releasing hormone (CRH) from the fetal
brain results in the secretion of adrenocorticotropic hormone
(ACTH) from the pituitary gland and cortisol from the adrenal
gland.13 The increase in cortisol parallels an increase in the secre-
tion of prostaglandin and estrogens and a fall in progesterone.13
Decreases in progesterone and increases in prostaglandins are
known triggers of uterine myometrium. Further support for the
role of the HPA axis in the initiation of labor is seen in studies
with hypophysectomized sheep; disruption of the HPA axis
results in prolonged pregnancy.14 More recent studies have pro-
posed a similar involvement of the HPA axis in human gestation,
and its dysregulation may play a role in prolonged pregnancies.
Early studies likened anencephaly to the hypophysectomized
sheep. It is hypothesized that the absence of the fetal brain in
the anencephalic fetus may result in a similar dysfunction of the
HPA axis and may lead to prolonged gestation. Epidemiologic
studies of anencephalic pregnancies have observed prolongation
of pregnancy.15 These findings support current thinking that the
interaction between the fetal brain and placenta plays an impor-
tant role in triggering labor.
Pregnancies complicated by placental sulfatase deficiency, an
X-linked recessive disorder characterized by the absence of the
enzyme steroid sulfatase, are marked by abnormally low estriol
levels and, in general, fail to go into spontaneous labor.16 This
is an example of a genetic etiology for prolonged pregnancy and
lends further support to the important role of the placenta in
the initiation of labor.
A number of observational studies have identified risk
factors for postterm pregnancy including primigravidity,
prior postterm pregnancy, male fetus, obesity, and a genetic
predisposition.17-23 A 10-year cohort study of births in Norway
failed to find a strong association of risk factors with postterm
pregnancy but may have had a bias toward nondetection.17
Intergenerational studies suggest a genetic predisposition for
postterm pregnancy. Mothers who themselves were postterm
also have an increased risk of prolonged pregnancy. Twin studies
have found higher rates of concordance for postterm pregnancy
among female twins, compared with male twins, implicating a
maternal influence on the risk for prolonged pregnancy.22
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
797
DIAGNOSIS
The diagnosis of truly late term and postterm pregnancy is
based on accurate gestational dating. The three most com-
monly used methods to determine the EDD are (1) knowledge
of the date of the LMP, (2) knowledge of the timing of inter-
course, and (3) early ultrasound assessment. Other methods have
been described but are rarely used in contemporary practice,
including the determination of uterine size, quickening, ability
to detect fetal heart tones by Doppler auscultation, and fundal
height measurement. In most cases, the date of conception is
rarely known and therefore is infrequently used to determine
gestational age. The EDD is most commonly assigned based on
the first day of the LMP, but this assumes that conception occurs
on the fourteenth day of the menstrual cycle. This method can be
very inaccurate because the timing of ovulation is variable among
an individuals menstrual cycles and between individuals.24,25
Basing gestational age solely on the LMP generally results in an
overestimation of gestational age and may result in a higher fre-
quency of induction of labor for presumed postterm pregnancy.
The use of ultrasound to determine the accuracy of gesta-
tional dating based on the LMP is superior to the use of the
LMP alone. The EDD is most accurately determined if the
crown-rump length is measured in the first trimester with an
error of 5 to 7 days. Boyd and colleagues26 showed that the
incidence of patients whose pregnancy exceeded 293 days was
7.5% based on menstrual dating and declined to 2.6% when
dates were determined by early sonographic examination. A
similar conclusion was reached by Gardosi and associates,27 who
evaluated 24,675 spontaneous, normal singleton deliveries and
showed a decline in the postterm (>294 days) pregnancy rate
from 9.5% when pregnancies were dated by LMP to 1.5% when
ultrasound dating was used. These authors also reported that
about 72% of routine labor inductions at 42 weeks gestation
were not indicated because they were performed before the
patients reached 42 weeks based on ultrasound assessment of
gestational age. Similarly, Nguyen and coworkers28 evaluated
14,805 spontaneous deliveries with a reliable LMP and showed
that ultrasound dating reduced the proportion of deliveries
beyond 294 days of gestation by 39% (from 7.9% to 5.2%).
Bennett and colleagues29 confirmed these findings in a prospec-
tive, randomized study of 218 women and found fewer postterm
inductions of labor in women dated by a first-trimester sono-
gram when compared with women whose dates were established
by second-trimester sonography.
PERINATAL MORBIDITY AND MORTALITY
Numerous studies have evaluated the risk to the fetus in late-
term and postterm pregnancies. Early descriptive studies found
that pregnancies that continued past their EDD had an increased
risk of fetal death. In 1963, McClure6 found a twofold increase
in fetal distress at 42 weeks with an increase in operative
deliveries and surmised that 42 weeks constituted a significant
risk to the fetus and proposed intervening with induction of
labor or cesarean delivery to avoid the risk of fetal death. Early
studies were likely fraught with inaccurate dating and inconsis-
tent definitions of postterm pregnancy. Lastly, it is important to
note that these studies included pregnancies complicated by fetal
anomalies, intrauterine growth restriction (IUGR), and mothers
with coexisting medical conditions, all of which increase the risk
of fetal demise.
798 Section VI Pregnancy and Coexisting Disease

More recent observational studies that have evaluated 6

the risk of perinatal mortality at each gestational week show
an increased risk as gestational age advances beyond the
EDD.30-32 Divon and associates33 evaluated fetal and neonatal 5 Neonatal death
mortality rates in 181,524 accurately dated full-term, late-term,

Mortality per 1000 ongoing pregnancies

Postneonatal death
and postterm pregnancies. A significant increase in fetal mortal-
Expressed per 1000
ity was detected from 41 weeks gestation onward (odds ratios
4 ongoing pregnancies
[ORs] of 1.5, 1.8, and 2.9 at 41, 42, and 43 weeks, respectively).
Campbell and colleagues17 performed a multivariate analysis of
factors associated with perinatal death among 65,796 singleton
postterm births (294 days). Three variables were identified as 3
independent predictors of perinatal mortality: (1) birthweight
lower than the 10th percentile for gestational age had a relative
risk (RR) of 5.7 and a 95% confidence interval (CI) of 4.4 2
to 7.4; (2) maternal age 35 years or greater had an RR of 1.88
and a 95% CI of 1.2 to 2.9; and (3) birthweight at the 90th
percentile for gestational age or above was associated with a
modest protective effect for perinatal death (RR, 0.51; 95% CI, 1
0.26 to 1.0).
Many of these studies have used perinatal mortality rate
(PMR), which has been suggested by Smith34 and others to be 0
an inappropriate assessment of risk to the fetus. The denomina- 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43+
tor in the calculation of the PMR is the number of deliveries.34-37 Gestational age (weeks)
As stated by Smith,34 Estimating the probability of an event
FIG 36-1 The summed mortality at each gestation for the rate of still-
requires that the number of events (numerator) be divided by birth (red), neonatal death (blue), and postneonatal death (green)
the number of subjects at risk for that event (denominator). expressed per 1000 ongoing pregnancies. (Modified from Hilder L,
Therefore it seems logical to calculate fetal mortality as fetal Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gesta-
deaths per 1000 ongoing pregnancies, rather than per 1000 tion specific risks of fetal and infant mortality. BJOG. 1998;105:169.)
deliveries. When Hilder and colleagues35 used ongoing pregnan-
cies in a large retrospective study that included 171,527 births,
higher rates of stillbirth were found. A nadir was seen at 41 TABLE 36-1 NEONATAL MORBIDITY IN POSTTERM
weeks, but compared with 37 weeks gestation, an eightfold AVERAGE AND SGA INFANTS
increase in stillbirths at 43 weeks was reported (Fig. 36-1). Using COMPLICATIONS TERM AGA NEONATES*
the Scottish birth registry, Smith37a also found a significant Convulsions
increase in the risk of stillbirth from 37 weeks (0.4/1000) to 43 Term SGA 2.3 (1.6-3.4)
weeks (11.5/1000). Postterm AGA 1.5 (1.2-2.0)
Several studies have examined the association of perinatal Postterm SGA 3.4 (1.5-7.6)
morbidity with postterm pregnancy. Clausson and colleagues38 Meconium Aspiration
Term SGA 2.4 (1.6-3.4)
evaluated a large Swedish database of term and postterm Postterm AGA 3.0 (2.6-3.7)
(defined as 294 days) singleton, normal neonates and showed Postterm SGA 1.6 (0.5-5.0)
that postterm pregnancies were associated with an increased Apgar Score <4 at 5min
frequency of neonatal convulsions, meconium aspiration Term SGA 2.2 (1.4-3.4)
Postterm AGA 2.0 (1.5-2.5)
syndrome, and Apgar scores of less than 4 at 5 minutes Postterm SGA 3.6 (1.5-8.7)
(Table 36-1). Tunon and associates39 compared neonatal inten-
sive care unit (NICU) admission rates among 10,048 term preg- Modified from Clausson B, Cnattinguis S, Axelsson O. Outcomes of post-term births:
the role of fetal growth restriction and malformations. Obstet Gynecol. 1999;94:758.
nancies and 246 postterm pregnancies (296 days by both scan *Values are presented as odds ratios (confidence interval).
and LMP dates). Postterm pregnancy was associated with a AGA, average for gestational age; SGA, small for gestational age.
significant increase in NICU admissions (OR, 2.05; 95% CI,
1.35 to 3.12).
Guidetti and colleagues40 reported an increased incidence of Doppler studies of renal blood flow are conflicting.43,44 Thus
perinatal morbidity at 41 weeks gestation or greater. Maternal the etiology of oligohydramnios in postterm pregnancies is still
and fetal complications were evaluated in a large (n = 45,673) debated.
retrospective cohort study by Caughey and Musci.41 These Regardless of the pathophysiology of oligohydramnios in
authors documented a significant increase in the rate of intra- postterm pregnancies, in a setting of oligohydramnios, the
uterine fetal death (IUFD) beyond 41 weeks. They concluded risk of perinatal morbidity and mortality is increased.45 The
that risks to both the mother and the infant increase as preg- importance of oligohydramnios was identified by Leveno and
nancy progresses beyond 40 weeks gestation. coworkers,46 who used its presence to explain the increased inci-
dence of abnormal antepartum and intrapartum fetal heart rate
Oligohydramnios (FHR) abnormalities seen in prolonged pregnancies. These
Oligohydramnios is a common finding in postterm pregnancies; authors suggested that prolonged FHR decelerations that repre-
it is presumably the result of fetal hypoxemia, which may result sented cord compression preceded 75% of cesarean deliveries for
in altered renal perfusion and decreased urine production.42 fetal jeopardy. The association between a reduced amniotic fluid

Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
 Chapter 36 Prolonged and Postterm Pregnancy
index (AFI) and variable decelerations is well documented and
is likely related to cord compression.47,48 Meconium passage in
amniotic fluid has also been associated with oligohydramnios,
and it is postulated that the hypoxemia may result in rectal
sphincter relaxation. Some studies have shown meconium-
stained fluid as high as 29% in postterm pregnancies com
plicated by oligohydramnios.49 See Chapter 35 for further
discussion of oligohydramnios.
A prospective, blinded observational study of 1584 preg
nancies was performed by Morris and colleagues50 to assess
the usefulness of ultrasound assessment of amniotic fluid in the
prediction of adverse outcome in prolonged pregnancies. The
authors demonstrated that an AFI of less than 5 cm, but not a
single deepest vertical pocket less than 2 cm, was significantly
associated with birth asphyxia or meconium aspiration. In addi-
tion, a significant association was found between an AFI of less
than 5 cm and fetal distress in labor, cord arterial pH less than
7.0, and low Apgar scores.
The presence of oligohydramnios is often cited as an indica-
tion for delivery of pregnancies that reach term gestation or
beyond. Importantly, no large, prospective, randomized studies
have documented the benefits of delivery in this setting.
Still, given the well-described association between oligohy-
dramnios and adverse pregnancy outcome at or beyond
term, delivery is a reasonable choice for patients with
oligohydramnios.
Fetal Growth
The risk of macrosomia has been shown to increase with
advancing gestational age, although the majority of prolonged
pregnancies are appropriately grown. In a sample of 7000 preg-
nancies between 39 and 42 weeks, McLean and coworkers51
found an increase in both fetal weight and head circumference.
Eden and associates52 observed that, compared with term preg-
nancies, postterm pregnancies have a twofold increase in the risk
for macrosomia; and in these pregnancies, macrosomia was asso-
ciated with a greater risk of operative delivery and shoulder
dystocia leading to fetal injury.
Chervenak and colleagues54 investigated the use of ultrasound
to evaluate the estimated fetal weight (EFW) in pregnancies
greater than 41 weeks and also found an increased incidence of
fetal weight greater than 4000 g. They also showed an increase
in the risk of cesarean delivery (22%) because of protracted and
arrested labors when compared with nonmacrosomic infants
(10%; P <.01). The positive and negative predictive values were
70% and 87%, respectively. However, a similar study of preg-
nancies at 41 weeks or greater found an absolute error of approx-
imately 8% and a positive predictive value of 64% when
ultrasound was used to estimate fetal weight within 1 week of
delivery.54 ACOG53 has warned that the diagnosis of fetal
macrosomia by ultrasound is not precise and that early
induction of labor or cesarean delivery has not been shown
to reduce the morbidity associated with fetal macrosomia.
Postmaturity
Postmaturity, another complication of prolonged pregnan-
cies, occurs in approximately 10% to 20% of such pregnan-
cies.55-57 The postmature infant has decreased subcutaneous fat
and lacks lanugo and vernix. The features are similar to those of
IUGR, and some authors believe that postmaturity is really
another manifestation of IUGR. Postmaturity is also associated
with an increased incidence of meconium-stained fluid.
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
799
Meconium
Meconium-stained fluid can be seen at any gestational age,
although several studies have documented a significantly in-
creased risk of meconium-stained fluid in postterm pregnancies.
Meconium aspiration is a serious neonatal condition that results
in decreased lung compliance, abnormal production of surfac-
tant, and a chemical pneumonitis (see Chapter 22).
MATERNAL COMPLICATIONS
Prolonged pregnancies are also associated with significant
risk to the mother. Not only is anxiety significant as the preg-
nancy advances beyond the EDD but the risk of maternal mor-
bidity during the intrapartum period is also increased. Caughey
and colleagues58 studied 119,254 women who delivered at 37
weeks and beyond and found an increased risk in significant
perineal laceration (OR, 1.19; 95% CI, 1.09 to 1.22), chorio-
amnionitis (OR, 1.32; 95% CI, 1.21 to 1.44), endomyometritis
(OR, 1.46; 95% CI, 1.14 to 1.87), postpartum hemorrhage
(OR, 1.21; 95% CI, 1.10 to 1.32), and cesarean delivery (OR,
1.28; 95% CI, 1.20 to 1.36). The indications for cesarean deliv-
ery in this study were nonreassuring FHR and cephalopelvic
disproportion.
MANAGEMENT
Accurate assessment of gestational age is paramount in the
management of late-term and postterm pregnancies. When
ultrasound is used to confirm menstrual dating, the incidence
of late-term and postterm pregnancies and unnecessary interven-
tions are decreased.59 Because late-term and postterm pregnan-
cies have an increased risk of fetal mortality, modern management
includes the use of antenatal fetal surveillance and carefully
timed intervention.
Antenatal Surveillance
Given the increased risk of stillbirth, antenatal surveillance
is recommended in the management of prolonged and post-
term pregnancies. Testing options for fetal surveillance include
monitoring of fetal kick counts, nonstress test (NST), contrac-
tion stress test (CST), biophysical profile (BPP), and modified
biophysical profile (NST and AFI). Few data are available with
adequate power to assess the timing of initiation or frequency
of fetal testing in prolonged pregnancies. However, based on
the studies on perinatal morbidity and mortality discussed
above, it would seem prudent to initiate fetal testing no later
than 41 weeks of gestation. A number of small studies suggest
that twice-weekly antepartum testing is superior to once a week
in prolonged pregnancies. Johnson and associates60 reported
results on twice-weekly testing with BPP in 293 patients followed
beyond 42 weeks. No stillbirths were observed in this small series.
No large randomized controlled trials (RCTs) have compared
different modalities of fetal surveillance in prolonged pregnan-
cies. One RCT of 145 pregnancies beyond 42 weeks compared
BPP with modified BPP (mBPP).61 This study found a signifi-
cant increase in abnormal testing in the mBPP group (42% vs.
20.5%, OR, 3.5; 99% CI, 1.3 to 9.1) but no difference in cord
blood gases and neonatal outcome between the two groups.
Studies have not shown one modality of antepartum surveillance
to be superior to another.61
ACOG proposed that amniotic fluid volume (AFV) should
be assessed when surveillance is initiated for late-term
800 Section VI Pregnancy and Coexisting Disease
pregnancies because oligohydramnios has been associated
with abnormal fetal heart tracings, umbilical cord compres-
sion, and meconium-stained fluid. Chamberlain and cowork-
ers62 studied 7582 complicated pregnancies and found an
increase in the risk of fetal demise with decreased amniotic fluid.
A paucity of data are available to demonstrate improved neo-
natal outcomes in postterm pregnancies when testing is used.
Still, given the well-described increase in stillbirth in postterm
pregnancies, ACOG currently recommends the initiation
of fetal surveillance at 41 weeks or beyond with assessment
of AFV.3
Umbilical artery Doppler measurements are sometimes used
in cases of suspected placental insufficiency, and hence it might
be imagined that this modality could be useful in postterm
pregnancies. However, umbilical artery Doppler measurements
have not been shown to be useful in the management of pro-
longed pregnancies.63
Expectant Management Versus Induction
of Labor
Until the recent ACOG guidelines, expectant management was
acceptable when the cervix was unfavorable. New evidence, as
discussed below, supports the induction of labor after 420/7
weeks and by 426/7 weeks to decrease the risk of perinatal
morbidity and mortality, and it may be considered for preg-
nancies between 410/7 weeks and 416/7 weeks.
Several clinical trials have compared induction of labor to
expectant management in pregnancies that have progressed
beyond their EDD. Hannah and associates64 performed one of
the largest clinical trials, wherein 3407 pregnant women were
randomized at 41 weeks to induction or expectant management
with fetal surveillance. Delivery was indicated if the pregnancy
reached 44 weeks or if fetal compromise was evident. No differ-
ence was reported in the perinatal mortality and neonatal mor-
bidity, although the rate of cesarean delivery was increased in
the expectantly managed group. No cases of fetal demise were
reported in the induction group, and two were reported in the
expectantly managed group.
Another RCT of 440 uncomplicated pregnancies performed
by the National Institute of Child Health and Human Develop-
ment (NICHD) Network of Maternal-Fetal Medicine Units
compared induction at 42 weeks versus expectant management
until cervical effacement, dilation, or evidence of fetal compro-
mise was apparent.65 The primary outcome was perinatal or
maternal death or a composite of variables for perinatal morbid-
ity. Secondary outcomes for this trial included cesarean delivery,
maternal infection, blood transfusion, severe variable or late
decelerations, and a 5-minute Apgar score less than 4. No dif-
ferences were detected in primary outcome or rates of cesarean
delivery. The study concluded that either induction or expectant
management at 42 weeks was deemed acceptable practice.
More recently, Sanchez-Ramos and colleagues66 published a
meta-analysis that included 16 RCTs and 6588 patients and
found a 20% rate of cesarean delivery in uncomplicated pregnan-
cies induced at 41 weeks compared with 22% in the expectantly
managed group. A nonsignificant but numerically lower perina-
tal mortality rate was reported for the induction group (0.09%
vs. 0.33%, OR, 0.41; 95% CI, 0.14 to 1.18). They also found
no differences in NICU admission and meconium aspiration.
The most recent Cochrane review,67 updated in 2012, is a
meta-analysis of 22 RCTs. The review included 9383 patients
and looked at the potential benefits or harms of labor induction
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
at or beyond 40 weeks gestation versus expectant management.
The primary outcome was perinatal mortality, which included
IUFD and neonatal death in the first week of life. Labor induc-
tion was associated with a small but significant reduction in
perinatal death (RR, 0.31; 95% CI, 0.12 to 0.88) with no
impact on the rate of cesarean delivery (RR, 0.89; 95% CI, 0.81
to 0.97). This Cochrane meta-analysis suggests that induc-
tion may yield slightly improved perinatal outcomes.
Labor Induction
Several studies have addressed membrane sweeping as a method
for labor induction in an attempt to reduce the occurrence of
postterm pregnancies (see Chapter 13). Membrane sweeping is
the digital separation of the membranes from the lower uterine
segment during a cervical examination. This practice is thought
to increase the levels of endogenous prostaglandin, which results
in uterine contractions. An RCT conducted by de Miranda and
colleagues68 enrolled 742 patients at 41 weeks gestation and
randomized them to serial sweeping of membranes every 48
hours until 42 weeks, or until labor was initiated, or to no
intervention. They found a decrease in the risk of postterm
pregnancy in the first group; 23% were postterm (RR, 0.57;
95% CI, 0.46 to 0.71) compared with 41% in the no-intervention
group. The number needed to treat (NNT) for this trial was six
patients. Previously published trials have not shown a significant
difference, but these studies limited membrane sweeping to a
single episode.69,70 The most recent Cochrane review of trials that
enrolled pregnant patients from 38 to 41 weeks to membrane
sweeping found a reduced rate of pregnancies that continued
past 41 weeks gestation, with an NNT of eight patients.71
Although this practice may be effective in some pregnant
patients, the procedure is known to cause maternal discomfort
and bleeding. Also, evidence is limited regarding membrane
sweeping in women colonized with group B Streptococcus. Thus
patients who can consider this option should be selected
carefully and counseled appropriately.
Some have attempted to predict the likelihood of successful
induction using transvaginal ultrasound of the cervix and fetal
fibronectin. Pandis and colleagues72 compared Bishop score with
ultrasound cervical assessment and found cervical length to be
more predictive of a successful labor induction than Bishop score
(with a sensitivity and specificity of 87% and 71% vs. 58% and
27%, respectively). Although the results of this study are promis-
ing, transvaginal ultrasound assessment of the cervix to predict
induction success is not commonly used. Attempts to evaluate
the role of a fetal fibronectin in cervical secretions as a predictor
of the onset of spontaneous labor have been inconclusive. In
fact, Rozenberg and associates73 have shown that the spontane-
ous onset of labor within 7 days of evaluation is predicted by a
Bishop score greater than 7 and a cervical length less than 25
mm but not with a positive fetal fibronectin (fFN).
Prostaglandins are most commonly used for labor induction
in patients with an unfavorable cervix or a Bishop score less
than 6. Studies have shown both misoprostol (prostaglandin
E1 [PGE1]) and dinoprostone (prostaglandin E2 [PGE2]) to
be efficacious in postterm pregnancy, and either preparation is
acceptable.64,65,74
LONG-TERM NEONATAL OUTCOMES
A paucity of information exists on neonates born at 42 weeks
and later. Ting and coworkers75 evaluated a population enrolled
 Chapter 36 Prolonged and Postterm Pregnancy
in the Collaborative Perinatal Study in Philadelphia and found
that surviving children could not be differentiated from their
matched controls either physically or mentally. Shime and col-
leagues76 found similar results in children followed at 1 and 2
years of age. They assessed intelligence by the Griffiths Mental
Development Scale and found no difference when these children
were compared with those from term births. Based on these
small and older studies, no difference in long-term neonatal
outcome is apparent.
MULTIPLE GESTATION
No defined gestational age cutoff has been established to
define a prolonged pregnancy in twin, triplet, or higher-
order multiples. The average gestation lengths for twin, triplet,
and quadruplet pregnancies are 36, 33, and 29 weeks, respec-
tively. The nadir of stillbirth occurs at 38 weeks for twins and
at 35 weeks for triplets, and it is unknown for quadruplets and
higher-order multiples.77 Intuitively, because we use rates of
perinatal mortality to define these cutoffs for singletons, we
should do the same for multiple gestations. No current strategies
have been recommended as these pregnancies approach the
above gestational ages, although it would seem reasonable to
utilize antenatal testing as these gestational ages approach
and to accomplish delivery at the nadir of stillbirth risk (see
Chapter 32).
KEY POINTS
Ultrasonography, preferably done in the first trimester,
is the most accurate method with which to establish the
EDD.
No gestational cutoff has been established by which to
define a prolonged pregnancy in multiple gestations.
The risk for stillbirth increases after 38 weeks in twins
and after 35 weeks in triplets.
Late-term and postterm pregnancies are associated with
an increased risk for perinatal morbidity and mortality,
oligohydramnios, macrosomia, postmaturity, and
maternal morbidity.
It seems prudent to initiate antenatal fetal surveillance
at 41 weeks in a normal, uncomplicated pregnancy in
the absence of IUGR.
Antenatal fetal surveillance at 41 weeks should include
an mBPP at least once a week.
If the cervix is favorable at 41 weeks, induction of labor
can be considered.
Delivery after 420/7 weeks and by 426/7 weeks is recom-
mended based on the small but increased risk of peri-
natal morbidity and mortality.
Either prostaglandin preparation, PGE1 or PGE2, can
be used for induction of the postterm pregnancy.
REFERENCES
1. Ballantyne JW. The problem of the postmature infant. J Obstet Gynaecol Br
Emp. 1902;2:521.
2. Clifford SH. Postmaturity with placental dysfunction, clinical syndrome
and pathologic findings. J Pediatr. 1954;44:1.
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
801
3. American College of Obstetricians and Gynecologists. Practice bulletin no.
146: Management of late-term and postterm pregnancies. Obstet Gynecol.
2014;124(2 Pt 1):390-396.
4. World Health Organization (WHO). Recommended definition terminol-
ogy and format for statistical tables related to the perinatal period and rise
of a new certification for cause of perinatal deaths. Modifications recom-
mended by FIGO as amended, October 14, 1976. Acta Obstet Gynecol
Scand. 1977;56:347.
5. Federation of Gynecology and Obstetrics (FIGO). Report of the FIGO
Subcommittee on Perinatal Epidemiology and Health Statistics Following a
Workshop in Cairo, November 11-18, 1984. London: International Federa-
tion of Gynecology and Obstetrics; 1986:54.
6. McClure-Brown JC. Postmaturity. JAMA. 1963;186(12):81.
7. ACOG Committee Opinion No 579. Definition of term pregnancy. Obstet
Gynecol. 2013;122:1139-1140.
8. Spong CY. Defining Term Pregnancy Recommendations From the Defin-
ing Term Pregnancy Workgroup. JAMA. 2013;309(23):2445.
9. Martin JA, Hamilton BE, Osterman MJ, etal. Births: Final data for 2012.
National vital statistics reports. Vol. 62 no 9. Hyattsville, MD: National
Center for Health Statistics; 2013.
10. Zeitlin J, Blondel B, Alexander S, Brart G, PERISTAT Group. Variation
in rates of postterm birth in Europe: reality or artefact? BJOG. 2007;
114(9):1097.
11. Gardosi J. Dating of pregnancy: time to forget the last menstrual period.
Ultrasound Obstet Gynecol. 1997;9:367.
12. Norwitz ER, Robinson JN, Challis JR. The control of labor. N Engl J Med.
1999;341:660.
13. Challis JR, Sloboda D, Matthews SG, etal. The fetal placental hypothalamic-
pituitary-adrenal (HPA) axis, parturition and postnatal health. Mol Cell
Endocrinol. 2001;185(12):135.
14. Nathanielsz PW. Endocrine mechanisms of parturition. Annu Rev Physiol.
1978;40:411.
15. Naeye RL, Blanc WA. Organ and body growth in anencephaly: A quantita-
tive, morphological study. Arch Pathol. 1971;91(2):140.
16. Rabe T, Hsch R, Runnebaum B. Sulfatase deficiency in the human pla-
centa: clinical findings. Biol Res Pregnancy Perinatol. 1983;4(3):95.
17. Campbell MK, Ostbye T, Irgens LM. Post-term birth: risk factors and
outcomes in a 10-year cohort of Norwegian births. Obstet Gynecol. 1997;
89:543.
18. Mogren I, Stenlund H, Hgberg U. Recurrence of prolonged pregnancy.
Int J Epidemiol. 1999;28:253.
19. Olesen AW, Basso O, Olsen J. Risk of recurrence of prolonged pregnancy.
BMJ. 2003;326:476.
20. Kistka ZA, Palomar L, Boslaugh SE, etal. Risk for postterm delivery after
previous postterm delivery. Am J Obstet Gynecol. 2007;196:241.
21. Divon MY, Ferber A, Nisell H, Westgren M. Male gender predisposes to
prolongation of pregnancy. Am J Obstet Gynecol. 2002;187:1081.
22. Laursen M, Billie C, Olesen AW, etal. Genetic influence on prolonged
gestation: a population-based Danish twin study. Am J Obstet Gynecol.
2004;190:489.
23. Stotland NE, Washington AE, Caughey AB. Prepregnancy body mass index
and the length of gestation at term. Am J Obstet Gynecol. 2007;197:378.
24. Munster K, Schmidt L, Helm P. Length and variation in the menstrual
cycle: a cross-sectional study from a Danish county. Br J Obstet Gynaecol.
1992;99(5):422.
25. Creinin MD, Keverline S, Meyn LA. How regular is regular? An analysis
of menstrual cycle regularity. Contraception. 2004;70(4):289.
26. Boyd ME, Usher RH, McLean FH, Kramer MS. Obstetric consequences
of postmaturity. Am J Obstet Gynecol. 1988;158:334.
27. Gardosi J, Vanner T, Francis A. Gestational age and induction of labor for
prolonged pregnancy. Br J Obstet Gynaecol. 1997;104:792.
28. Nguyen TH, Larsen T, Engholm G, Mller H. Evaluation of ultrasound-
estimated date of delivery in 17,450 spontaneous singleton births: do we
need to modify Naegeles rule? Ultrasound Obstet Gynecol. 1999;14:23.
29. Bennett KA, Crane JM, OShea P, etal. First trimester ultrasound screening
is effective in reducing postterm labor induction rates: a randomized con-
trolled trial. Am J Obstet Gynecol. 2004;190:1077.
30. Ingemarsson I, Kallen K. Stillbirths and rate of neonatal deaths in 76,761
postterm pregnancies in Sweden, 1982-1991: a register study. Acta Obstet
Gynecol Scand. 1997;76:658.
31. Yudkin PL, Wood L, Redman CW. Risk of unexplained stillbirth at differ-
ent gestational ages. Lancet. 1987;1:1192.
32. Feldman GB. Prospective risk of stillbirth. Obstet Gynecol. 1992;79:547.
33. Divon MY, Haglund B, Nisell H, etal. Fetal and neonatal mortality in the
post-term pregnancy: the impact of gestational age and fetal growth restric-
tion. Am J Obstet Gynecol. 1998;178:726.
802 Section VI Pregnancy and Coexisting Disease
34. Smith GC. Estimating risks of perinatal death. Am J Obstet Gynecol.
2005;192:17.
35. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating
gestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol.
1998;105:169.
36. Cotzias CS, Paterson-Brown S, Fisk NM. Prospective risk of unexplained
stillbirth in singleton pregnancies at term: population based analysis. BMJ.
1999;319:287.
37. Huang DY, Usher RH, Kramer MS, etal. Determinants of unexplained
antepartum fetal deaths. Obstet Gynecol. 2000;95:215.
37a. Smith GC. Life-table analysis of the risk of perinatal death at term and
post term in singleton pregnancies. Am J Obstet Gynecol. 2001;184:
489-496.
38. Clausson B, Cnattingius S, Axelsson O. Outcomes of post-term births: the
role of fetal growth restriction and malformations. Obstet Gynecol. 1999;
94:758.
39. Tunon K, Eik-Nes SH, Grottum P. Fetal outcome in pregnancies defined
as post-term according to the last menstrual period estimate, but not accord-
ing to the ultrasound estimate. Ultrasound Obstet Gynecol. 1999;14:12.
40. Guidetti DA, Divon MY, Langer O. Postdate fetal surveillance: is 41 weeks
too early? Am J Obstet Gynecol. 1989;161:91.
41. Caughey AB, Musci TJ. Complications of term pregnancies beyond 37
weeks of gestation. Obstet Gynecol. 2004;103:57.
42. Nicolaides KH, Peters MT, Vyas S, etal. Relation of rate of urine produc-
tion to oxygen tension in small for gestational age fetuses. Am J Obstet
Gynecol. 1990;162:387.
43. Gresham EL, Rankin JH, Makowski EL, Meschia G, Battaglia FC. An
evaluation of fetal renal function in chronic sheep preparation. J Clin Invest.
1972;51:149.
44. Bar-Hava I, Divon MY, Sardo M, Barnhard Y. Is oligohydramnios in post-
term pregnancy associated with redistribution of fetal blood flow? Am J
Obstet Gynecol. 1995;173:519.
45. Phelan JP, Ahn MO, Smith CV, etal. Amniotic fluid index measurements
during pregnancy. J Reprod Med. 1987;32:601.
46. Leveno KJ, Quirk JG Jr, Cunningham FG, etal. Prolonged pregnancy. I.
Observations concerning the causes of fetal distress. Am J Obstet Gynecol.
1984;150:465.
47. Gabbe SG, Ettinger BB, Freeman RK, Martin CB. Umbilical cord compres-
sion associated with amniotomy: laboratory observations. Am J Obstet
Gynecol. 1976;126:353.
48. Miyazaki FS, Taylor NA. Saline amnioinfusion for relief of variable or
prolonged decelerations. A preliminary report. Am J Obstet Gynecol. 1983;
146:670.
49. Crowley P, OHerlihy C, Boylan P. The value of ultrasound measurement
of amniotic fluid volume in management of prolonged pregnancies. Br J
Obstet Gynaecol. 1984;91:444.
50. Morris JM, Thompson K, Smithey J, etal. The usefulness of ultrasound
assessment of amniotic fluid in predicting adverse outcome in prolonged
pregnancy: a prospective blinded observational study. Br J Obstet Gynecol.
2003;110:989.
51. McLean FH, Boyd ME, Usher RH, Kramer MS. Post-term infants: too big
or too small? Am J Obstet Gynecol. 1991;164:619.
52. Eden RD, Seifert LS, Winegar A, Spellacy WN. Perinatal characteristics of
uncomplicated postdate pregnancies. Obstet Gynecol. 1987;69(3 Pt 1):296.
53. ACOG Practice Bulletin. Fetal macrosomia, No. 22, 2000.
54. Chervenak LJ, Divon MY, Hirsch J, etal. Macrosomia in the post-date
pregnancy: is routine sonography screening indicated? Am J Obstet Gynecol.
1989;161:753.
55. Shime J, Librach CL, Gare DJ, Cook CJ. The influence of prolonged
pregnancy on infant development at one and two years of age: a prospective
controlled study. Am J Obstet Gynecol. 1986;154:341.
56. Vorherr H. Placental insufficiency in relation to postterm pregnancy and
fetal postmaturity. Evaluation of fetoplacental function; management of
postterm gravida. Am J Obstet Gynecol. 1975;123:67.
Downloaded for april april linawati dewi (april.linawati.d@mail.ugm.ac.id) at Universitas Gadjah Mada from ClinicalKey.com by Elsevier on November 21, 2017.
For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
57. Mannino F. Neonatal complications of postterm gestation. J Reprod Med.
1988;33:271.
58. Caughey AB, Stotland NE, Washington AE, Escobar GJ. Maternal and
obstetric complications of pregnancy are associated with increasing gesta-
tional age at term. Am J Obstet Gynecol. 2007;196:155.
59. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal
assessment in early pregnancy. Cochrane Database Syst Rev. 2010;(4):
CD007058.
60. Johnson JM, Harman CR, Lange IR, Manning FA. Biophysical profile
scoring in the management of the post term pregnancy: an analysis of 307
patients. Am J Obstet Gynecol. 1986;154:269.
61. Alfirevic Z, Walkinshaw SA. A randomized controlled trial of simple com-
pared with complex antenatal fetal monitoring after 42 weeks gestation. Br
J Obstet Gynaecol. 1995;102(8):638.
62. Chamberlain PF, Manning FA, Morrison I, etal. Ultrasound evaluation of
amniotic fluid volume. I. The relationship of marginal and decreased amni-
otic fluid volumes to perinatal outcome. Am J Obstet Gynecol. 1984;150:
245.
63. Zimmermann P, Alback T, Koskinen J, etal. Doppler flow velocimetry of
the umbilical artery, uteroplacental arteries and fetal middle cerebral artery
in prolonged pregnancy. Ultrasound Obstet Gynecol. 1995;5:189.
64. Hannah ME, Hannah WJ, Hellman J, etal. Induction of labor as compared
with serial antenatal monitoring in post-term pregnancies. A randomized
controlled trial. The Canadian Multicenter Post-term Pregnancy Trial
Group. N Engl J Med. 1992;327:1587.
65. The National Institute of Child Health and Human Development Network
of Maternal Fetal Medicine Units. A clinical trial of induction of labor
versus expectant management in post term pregnancy. Am J Obstet Gynecol.
1994;170:716.
66. Sanchez-Ramos L, Olivier F, Delke I, Kaunitz AM. Labor induction versus
expectant management for postterm pregnancies: a systematic review with
meta-analysis. Obstet Gynecol. 2003;101:1312.
67. Glmezoglu AM, Crowther CA, Middleton P. Induction of labour for
improving birth outcomes for women at or beyond term. Cochrane Database
Syst Rev. 2012;(4):CD004945.
68. de Miranda E, van der Bom JG, Bonsel GJ, etal. Membrane sweeping and
prevention of post-term pregnancy in low-risk pregnancies: a randomised
controlled trial. BJOG. 2006;113(4):402.
69. Crane J, Bennett K, Young D, etal. The effectiveness of sweeping mem-
branes at term: a randomized trial. Obstet Gynecol. 1997;89(4):586.
70. Wong SF, Hui SK, Choi H, Ho LC. Does sweeping of membranes beyond
40 weeks reduce the need for formal induction of labour? BJOG. 2002;
109(6):632.
71. Boulvain M, Stan CM, Irion O. Membrane sweeping for induction of
labour. Cochrane Database Syst Rev. 2005;(1):CD000451.
72. Pandis GK, Papageorghiou AT, Ramanathan VG, etal. Preinduction sono-
graphic measurement of cervical length in the prediction of successful
induction. Ultrasound Obstet Gynecol. 2001;18:623.
73. Rozenberg P, Goffinet F, Hessabi M. Comparison of the Bishop score
ultrasonographically measured cervical length, and fetal fibronectin assay in
predicating time until delivery and type of delivery at term. Am J Obstet
Gynecol. 2000;182:108.
74. Meydanli MM, Caliskan E, Burak F, etal. Labor induction post-term with
25 micrograms vs. 50 micrograms of intravaginal misoprostol. Int J Gynaecol
Obstet. 2003;81(3):249.
75. Ting RV, Wang MH, Scott TF. The dysmature infant: associated factors and
outcome at 7 years of age. J Pediatr. 1977;90:943.
76. Shime J, Librach CL, Gare DJ, Cook CJ. The influence of prolonged
pregnancy on infant development at one and two years of age: a prospective
controlled study. Am J Obstet Gynecol. 1986;154:341.
77. Luke B. Reducing fetal deaths in multiple births: optimal birthweights and
gestational ages for infants of twin and triplet births. Acta Genet Med Gemel-
lol (Roma). 1996;45:333.