Chapter 36

Prolonged and
Postterm Pregnancy
ROXANE RAMPERSAD and GEORGE A. MACONES

Definition 796 Postmaturity 799 Labor Induction 800

Incidence 796 Meconium 799 Long-Term Neonatal
Etiology 797 Maternal Complications 799 Outcomes 800
Diagnosis 797 Management 799 Multiple Gestation 801
Perinatal Morbidity and Mortality 797 Antenatal Surveillance 799
Oligohydramnios 798 Expectant Management Versus Induction
Fetal Growth 799 of Labor 800

KEY ABBREVIATIONS DEFINITION

American College of Obstetricians and ACOG The American College of Obstetricians and Gynecologists
Gynecologists (ACOG), International Federation of Gynecology and Obstet-
Amniotic fluid index AFI rics (FIGO), and the World Health Organization (WHO) have
Confidence interval CI defined a postterm pregnancy as a gestation that has com-
Estimated date of delivery EDD pleted or gone beyond 42, weeks or 294 days, from the first
International Federation of Gynecology FIGO day of the last menstrual period (LMP).3-5 This gestational age
and Obstetrics cutoff has been used for several decades and was first suggested
Last menstrual period LMP based on early studies that reported an increased risk of fetal
Odds ratio OR death at 42 weeks and beyond.6 However, in view of more recent
Perinatal mortality rate PMR perinatal mortality data derived from accurately dated pregnan-
Randomized controlled trial RCT cies, it would be reasonable to conclude that the gestational
Relative risk RR age that warrants clinical concern should be 41 weeks.
Society for Maternal-Fetal Medicine SMFM Many terms have been used in the literature, including post-
World Health Organization WHO 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,
Obstetricians have long recognized the detrimental effects of patients, and researchers and to designate gestational ages at
preterm delivery, but for the last century, there has also been higher risk.7-8 Pregnancies are now designated to be early term
concern for pregnancies that have gone beyond the normal if they are 370/7 weeks through 386/7 weeks. Full term is defined
period of gestation. Early descriptions from prolonged pregnan- at 390/7 weeks through 406/7 weeks. Pregnancies are to be des-
cies described a large fetus and resulted in a difficult delivery ignated as late term if they are 410/7 weeks through 416/7
with an increased risk of stillbirth.1 Later descriptions suggested weeks. Postterm will continue to be defined as 420/7 weeks
that a postterm fetus not only could be large but also small for and beyond.
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 INCIDENCE
the upper limit of pregnancy was not well defined and the risks According to the vital statistics reported by the Centers
were inconsistent. More recent studies show a small but sig- for Disease Control and Prevention (CDC), the overall inci-
nificantly increased risk in perinatal morbidity and mortality dence of postterm pregnancies was 5.6% in 2012 and has
in postterm pregnancies, and hence, postterm pregnancy is not significantly changed compared with previous years.9
one of the most common reasons for induction of labor in Other published studies have shown varying frequency of post-
the United States. term pregnancies depending on the population studied. The

796
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 Chapter 36 Prolonged and Postterm Pregnancy 797

incidence of prolonged pregnancies in European countries also

varies widely, with rates as low as 0.4% in Austria and as high DIAGNOSIS
as 7% in Denmark and Sweden.10 These differences are most The diagnosis of truly late term and postterm pregnancy is
likely explained by different approaches for managing pregnan- based on accurate gestational dating. The three most com-
cies beyond the estimated date of delivery (EDD) and different monly used methods to determine the EDD are (1) knowledge
criteria for gestational age dating. 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,
ETIOLOGY including the determination of uterine size, quickening, ability
The etiology of the majority of pregnancies that are late term to detect fetal heart tones by Doppler auscultation, and fundal
or postterm is unknown, but some pregnancies may be height measurement. In most cases, the date of conception is
defined as late term or postterm as the result of an error in rarely known and therefore is infrequently used to determine
dating. It is common practice to assign an EDD based on the gestational age. The EDD is most commonly assigned based on
LMP. This practice has been proven by several studies to be the first day of the LMP, but this assumes that conception occurs
unreliable and may have led to the incorrect classification of a on the fourteenth day of the menstrual cycle. This method can be
pregnancy as late term or postterm.11 very inaccurate because the timing of ovulation is variable among
Understanding the events that lead to parturition in human an individuals menstrual cycles and between individuals.24,25
gestation may help to provide clues to the pathophysiology in Basing gestational age solely on the LMP generally results in an
prolonged pregnancies. Parturition is the result of a complex overestimation of gestational age and may result in a higher fre-
interplay among the mother, fetus, and placenta.12 The mech- quency of induction of labor for presumed postterm pregnancy.
anism in human gestation is unknown but may be similar to The use of ultrasound to determine the accuracy of gesta-
that of other mammals. In sheep, the hypothalamic-pituitary- tional dating based on the LMP is superior to the use of the
adrenal (HPA) axis is important in the timing of birth. The LMP alone. The EDD is most accurately determined if the
release of corticotropin-releasing hormone (CRH) from the fetal crown-rump length is measured in the first trimester with an
brain results in the secretion of adrenocorticotropic hormone error of 5 to 7 days. Boyd and colleagues26 showed that the
(ACTH) from the pituitary gland and cortisol from the adrenal incidence of patients whose pregnancy exceeded 293 days was
gland.13 The increase in cortisol parallels an increase in the secre- 7.5% based on menstrual dating and declined to 2.6% when
tion of prostaglandin and estrogens and a fall in progesterone.13 dates were determined by early sonographic examination. A
Decreases in progesterone and increases in prostaglandins are similar conclusion was reached by Gardosi and associates,27 who
known triggers of uterine myometrium. Further support for the evaluated 24,675 spontaneous, normal singleton deliveries and
role of the HPA axis in the initiation of labor is seen in studies showed a decline in the postterm (>294 days) pregnancy rate
with hypophysectomized sheep; disruption of the HPA axis from 9.5% when pregnancies were dated by LMP to 1.5% when
results in prolonged pregnancy.14 More recent studies have pro- ultrasound dating was used. These authors also reported that
posed a similar involvement of the HPA axis in human gestation, about 72% of routine labor inductions at 42 weeks gestation
and its dysregulation may play a role in prolonged pregnancies. were not indicated because they were performed before the
Early studies likened anencephaly to the hypophysectomized patients reached 42 weeks based on ultrasound assessment of
sheep. It is hypothesized that the absence of the fetal brain in gestational age. Similarly, Nguyen and coworkers28 evaluated
the anencephalic fetus may result in a similar dysfunction of the 14,805 spontaneous deliveries with a reliable LMP and showed
HPA axis and may lead to prolonged gestation. Epidemiologic that ultrasound dating reduced the proportion of deliveries
studies of anencephalic pregnancies have observed prolongation beyond 294 days of gestation by 39% (from 7.9% to 5.2%).
of pregnancy.15 These findings support current thinking that the Bennett and colleagues29 confirmed these findings in a prospec-
interaction between the fetal brain and placenta plays an impor- tive, randomized study of 218 women and found fewer postterm
tant role in triggering labor. inductions of labor in women dated by a first-trimester sono-
Pregnancies complicated by placental sulfatase deficiency, an gram when compared with women whose dates were established
X-linked recessive disorder characterized by the absence of the by second-trimester sonography.
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 PERINATAL MORBIDITY AND MORTALITY
lends further support to the important role of the placenta in Numerous studies have evaluated the risk to the fetus in late-
the initiation of labor. term and postterm pregnancies. Early descriptive studies found
A number of observational studies have identified risk that pregnancies that continued past their EDD had an increased
factors for postterm pregnancy including primigravidity, risk of fetal death. In 1963, McClure6 found a twofold increase
prior postterm pregnancy, male fetus, obesity, and a genetic in fetal distress at 42 weeks with an increase in operative
predisposition.17-23 A 10-year cohort study of births in Norway deliveries and surmised that 42 weeks constituted a significant
failed to find a strong association of risk factors with postterm risk to the fetus and proposed intervening with induction of
pregnancy but may have had a bias toward nondetection.17 labor or cesarean delivery to avoid the risk of fetal death. Early
Intergenerational studies suggest a genetic predisposition for studies were likely fraught with inaccurate dating and inconsis-
postterm pregnancy. Mothers who themselves were postterm tent definitions of postterm pregnancy. Lastly, it is important to
also have an increased risk of prolonged pregnancy. Twin studies note that these studies included pregnancies complicated by fetal
have found higher rates of concordance for postterm pregnancy anomalies, intrauterine growth restriction (IUGR), and mothers
among female twins, compared with male twins, implicating a with coexisting medical conditions, all of which increase the risk
maternal influence on the risk for prolonged pregnancy.22 of fetal demise.

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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

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 Chapter 36 Prolonged and Postterm Pregnancy 799

index (AFI) and variable decelerations is well documented and Meconium

is likely related to cord compression.47,48 Meconium passage in Meconium-stained fluid can be seen at any gestational age,
amniotic fluid has also been associated with oligohydramnios, although several studies have documented a significantly in-
and it is postulated that the hypoxemia may result in rectal creased risk of meconium-stained fluid in postterm pregnancies.
sphincter relaxation. Some studies have shown meconium- Meconium aspiration is a serious neonatal condition that results
stained fluid as high as 29% in postterm pregnancies com in decreased lung compliance, abnormal production of surfac-
plicated by oligohydramnios.49 See Chapter 35 for further tant, and a chemical pneumonitis (see Chapter 22).
discussion of oligohydramnios.
A prospective, blinded observational study of 1584 preg
nancies was performed by Morris and colleagues50 to assess MATERNAL COMPLICATIONS
the usefulness of ultrasound assessment of amniotic fluid in the Prolonged pregnancies are also associated with significant
prediction of adverse outcome in prolonged pregnancies. The risk to the mother. Not only is anxiety significant as the preg-
authors demonstrated that an AFI of less than 5 cm, but not a nancy advances beyond the EDD but the risk of maternal mor-
single deepest vertical pocket less than 2 cm, was significantly bidity during the intrapartum period is also increased. Caughey
associated with birth asphyxia or meconium aspiration. In addi- and colleagues58 studied 119,254 women who delivered at 37
tion, a significant association was found between an AFI of less weeks and beyond and found an increased risk in significant
than 5 cm and fetal distress in labor, cord arterial pH less than perineal laceration (OR, 1.19; 95% CI, 1.09 to 1.22), chorio-
7.0, and low Apgar scores. amnionitis (OR, 1.32; 95% CI, 1.21 to 1.44), endomyometritis
The presence of oligohydramnios is often cited as an indica- (OR, 1.46; 95% CI, 1.14 to 1.87), postpartum hemorrhage
tion for delivery of pregnancies that reach term gestation or (OR, 1.21; 95% CI, 1.10 to 1.32), and cesarean delivery (OR,
beyond. Importantly, no large, prospective, randomized studies 1.28; 95% CI, 1.20 to 1.36). The indications for cesarean deliv-
have documented the benefits of delivery in this setting. ery in this study were nonreassuring FHR and cephalopelvic
Still, given the well-described association between oligohy- disproportion.
dramnios and adverse pregnancy outcome at or beyond
term, delivery is a reasonable choice for patients with
oligohydramnios. MANAGEMENT
Accurate assessment of gestational age is paramount in the
Fetal Growth management of late-term and postterm pregnancies. When
The risk of macrosomia has been shown to increase with ultrasound is used to confirm menstrual dating, the incidence
advancing gestational age, although the majority of prolonged of late-term and postterm pregnancies and unnecessary interven-
pregnancies are appropriately grown. In a sample of 7000 preg- tions are decreased.59 Because late-term and postterm pregnan-
nancies between 39 and 42 weeks, McLean and coworkers51 cies have an increased risk of fetal mortality, modern management
found an increase in both fetal weight and head circumference. includes the use of antenatal fetal surveillance and carefully
Eden and associates52 observed that, compared with term preg- timed intervention.
nancies, postterm pregnancies have a twofold increase in the risk
for macrosomia; and in these pregnancies, macrosomia was asso- Antenatal Surveillance
ciated with a greater risk of operative delivery and shoulder Given the increased risk of stillbirth, antenatal surveillance
dystocia leading to fetal injury. is recommended in the management of prolonged and post-
Chervenak and colleagues54 investigated the use of ultrasound term pregnancies. Testing options for fetal surveillance include
to evaluate the estimated fetal weight (EFW) in pregnancies monitoring of fetal kick counts, nonstress test (NST), contrac-
greater than 41 weeks and also found an increased incidence of tion stress test (CST), biophysical profile (BPP), and modified
fetal weight greater than 4000 g. They also showed an increase biophysical profile (NST and AFI). Few data are available with
in the risk of cesarean delivery (22%) because of protracted and adequate power to assess the timing of initiation or frequency
arrested labors when compared with nonmacrosomic infants of fetal testing in prolonged pregnancies. However, based on
(10%; P <.01). The positive and negative predictive values were the studies on perinatal morbidity and mortality discussed
70% and 87%, respectively. However, a similar study of preg- above, it would seem prudent to initiate fetal testing no later
nancies at 41 weeks or greater found an absolute error of approx- than 41 weeks of gestation. A number of small studies suggest
imately 8% and a positive predictive value of 64% when that twice-weekly antepartum testing is superior to once a week
ultrasound was used to estimate fetal weight within 1 week of in prolonged pregnancies. Johnson and associates60 reported
delivery.54 ACOG53 has warned that the diagnosis of fetal results on twice-weekly testing with BPP in 293 patients followed
macrosomia by ultrasound is not precise and that early beyond 42 weeks. No stillbirths were observed in this small series.
induction of labor or cesarean delivery has not been shown No large randomized controlled trials (RCTs) have compared
to reduce the morbidity associated with fetal macrosomia. different modalities of fetal surveillance in prolonged pregnan-
cies. One RCT of 145 pregnancies beyond 42 weeks compared
Postmaturity BPP with modified BPP (mBPP).61 This study found a signifi-
Postmaturity, another complication of prolonged pregnan- cant increase in abnormal testing in the mBPP group (42% vs.
cies, occurs in approximately 10% to 20% of such pregnan- 20.5%, OR, 3.5; 99% CI, 1.3 to 9.1) but no difference in cord
cies.55-57 The postmature infant has decreased subcutaneous fat blood gases and neonatal outcome between the two groups.
and lacks lanugo and vernix. The features are similar to those of Studies have not shown one modality of antepartum surveillance
IUGR, and some authors believe that postmaturity is really to be superior to another.61
another manifestation of IUGR. Postmaturity is also associated ACOG proposed that amniotic fluid volume (AFV) should
with an increased incidence of meconium-stained fluid. be assessed when surveillance is initiated for late-term

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800 Section VI Pregnancy and Coexisting Disease

pregnancies because oligohydramnios has been associated at or beyond 40 weeks gestation versus expectant management.
with abnormal fetal heart tracings, umbilical cord compres- The primary outcome was perinatal mortality, which included
sion, and meconium-stained fluid. Chamberlain and cowork- IUFD and neonatal death in the first week of life. Labor induc-
ers62 studied 7582 complicated pregnancies and found an tion was associated with a small but significant reduction in
increase in the risk of fetal demise with decreased amniotic fluid. perinatal death (RR, 0.31; 95% CI, 0.12 to 0.88) with no
A paucity of data are available to demonstrate improved neo- impact on the rate of cesarean delivery (RR, 0.89; 95% CI, 0.81
natal outcomes in postterm pregnancies when testing is used. to 0.97). This Cochrane meta-analysis suggests that induc-
Still, given the well-described increase in stillbirth in postterm tion may yield slightly improved perinatal outcomes.
pregnancies, ACOG currently recommends the initiation
of fetal surveillance at 41 weeks or beyond with assessment Labor Induction
of AFV.3 Several studies have addressed membrane sweeping as a method
Umbilical artery Doppler measurements are sometimes used for labor induction in an attempt to reduce the occurrence of
in cases of suspected placental insufficiency, and hence it might postterm pregnancies (see Chapter 13). Membrane sweeping is
be imagined that this modality could be useful in postterm the digital separation of the membranes from the lower uterine
pregnancies. However, umbilical artery Doppler measurements segment during a cervical examination. This practice is thought
have not been shown to be useful in the management of pro- to increase the levels of endogenous prostaglandin, which results
longed pregnancies.63 in uterine contractions. An RCT conducted by de Miranda and
colleagues68 enrolled 742 patients at 41 weeks gestation and
Expectant Management Versus Induction randomized them to serial sweeping of membranes every 48
of Labor hours until 42 weeks, or until labor was initiated, or to no
Until the recent ACOG guidelines, expectant management was intervention. They found a decrease in the risk of postterm
acceptable when the cervix was unfavorable. New evidence, as pregnancy in the first group; 23% were postterm (RR, 0.57;
discussed below, supports the induction of labor after 420/7 95% CI, 0.46 to 0.71) compared with 41% in the no-intervention
weeks and by 426/7 weeks to decrease the risk of perinatal group. The number needed to treat (NNT) for this trial was six
morbidity and mortality, and it may be considered for preg- patients. Previously published trials have not shown a significant
nancies between 410/7 weeks and 416/7 weeks. difference, but these studies limited membrane sweeping to a
Several clinical trials have compared induction of labor to single episode.69,70 The most recent Cochrane review of trials that
expectant management in pregnancies that have progressed enrolled pregnant patients from 38 to 41 weeks to membrane
beyond their EDD. Hannah and associates64 performed one of sweeping found a reduced rate of pregnancies that continued
the largest clinical trials, wherein 3407 pregnant women were past 41 weeks gestation, with an NNT of eight patients.71
randomized at 41 weeks to induction or expectant management Although this practice may be effective in some pregnant
with fetal surveillance. Delivery was indicated if the pregnancy patients, the procedure is known to cause maternal discomfort
reached 44 weeks or if fetal compromise was evident. No differ- and bleeding. Also, evidence is limited regarding membrane
ence was reported in the perinatal mortality and neonatal mor- sweeping in women colonized with group B Streptococcus. Thus
bidity, although the rate of cesarean delivery was increased in patients who can consider this option should be selected
the expectantly managed group. No cases of fetal demise were carefully and counseled appropriately.
reported in the induction group, and two were reported in the Some have attempted to predict the likelihood of successful
expectantly managed group. induction using transvaginal ultrasound of the cervix and fetal
Another RCT of 440 uncomplicated pregnancies performed fibronectin. Pandis and colleagues72 compared Bishop score with
by the National Institute of Child Health and Human Develop- ultrasound cervical assessment and found cervical length to be
ment (NICHD) Network of Maternal-Fetal Medicine Units more predictive of a successful labor induction than Bishop score
compared induction at 42 weeks versus expectant management (with a sensitivity and specificity of 87% and 71% vs. 58% and
until cervical effacement, dilation, or evidence of fetal compro- 27%, respectively). Although the results of this study are promis-
mise was apparent.65 The primary outcome was perinatal or ing, transvaginal ultrasound assessment of the cervix to predict
maternal death or a composite of variables for perinatal morbid- induction success is not commonly used. Attempts to evaluate
ity. Secondary outcomes for this trial included cesarean delivery, the role of a fetal fibronectin in cervical secretions as a predictor
maternal infection, blood transfusion, severe variable or late of the onset of spontaneous labor have been inconclusive. In
decelerations, and a 5-minute Apgar score less than 4. No dif- fact, Rozenberg and associates73 have shown that the spontane-
ferences were detected in primary outcome or rates of cesarean ous onset of labor within 7 days of evaluation is predicted by a
delivery. The study concluded that either induction or expectant Bishop score greater than 7 and a cervical length less than 25
management at 42 weeks was deemed acceptable practice. mm but not with a positive fetal fibronectin (fFN).
More recently, Sanchez-Ramos and colleagues66 published a Prostaglandins are most commonly used for labor induction
meta-analysis that included 16 RCTs and 6588 patients and in patients with an unfavorable cervix or a Bishop score less
found a 20% rate of cesarean delivery in uncomplicated pregnan- than 6. Studies have shown both misoprostol (prostaglandin
cies induced at 41 weeks compared with 22% in the expectantly E1 [PGE1]) and dinoprostone (prostaglandin E2 [PGE2]) to
managed group. A nonsignificant but numerically lower perina- be efficacious in postterm pregnancy, and either preparation is
tal mortality rate was reported for the induction group (0.09% acceptable.64,65,74
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 LONG-TERM NEONATAL OUTCOMES
meta-analysis of 22 RCTs. The review included 9383 patients A paucity of information exists on neonates born at 42 weeks
and looked at the potential benefits or harms of labor induction and later. Ting and coworkers75 evaluated a population enrolled

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 Chapter 36 Prolonged and Postterm Pregnancy 801

in the Collaborative Perinatal Study in Philadelphia and found 3. American College of Obstetricians and Gynecologists. Practice bulletin no.
that surviving children could not be differentiated from their 146: Management of late-term and postterm pregnancies. Obstet Gynecol.
2014;124(2 Pt 1):390-396.
matched controls either physically or mentally. Shime and col- 4. World Health Organization (WHO). Recommended definition terminol-
leagues76 found similar results in children followed at 1 and 2 ogy and format for statistical tables related to the perinatal period and rise
years of age. They assessed intelligence by the Griffiths Mental of a new certification for cause of perinatal deaths. Modifications recom-
Development Scale and found no difference when these children mended by FIGO as amended, October 14, 1976. Acta Obstet Gynecol
Scand. 1977;56:347.
were compared with those from term births. Based on these 5. Federation of Gynecology and Obstetrics (FIGO). Report of the FIGO
small and older studies, no difference in long-term neonatal Subcommittee on Perinatal Epidemiology and Health Statistics Following a
outcome is apparent. 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.
MULTIPLE GESTATION 7. ACOG Committee Opinion No 579. Definition of term pregnancy. Obstet
Gynecol. 2013;122:1139-1140.
No defined gestational age cutoff has been established to 8. Spong CY. Defining Term Pregnancy Recommendations From the Defin-
define a prolonged pregnancy in twin, triplet, or higher- ing Term Pregnancy Workgroup. JAMA. 2013;309(23):2445.
order multiples. The average gestation lengths for twin, triplet, 9. Martin JA, Hamilton BE, Osterman MJ, etal. Births: Final data for 2012.
National vital statistics reports. Vol. 62 no 9. Hyattsville, MD: National
and quadruplet pregnancies are 36, 33, and 29 weeks, respec- Center for Health Statistics; 2013.
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