Post Date8
Post Date8
Review
Postterm pregnancy
M. Galal1, i. SyMOndS2, H. MuRRay3, F. PetRaGlia4, R. SMitH5
1
Consultant/Conjoint Senior Lecturer in Obstetrics & Gynaecology, John Hunter Hospital, University of Newcastle, New
South Wales, Australia.
2
Professor of Obstetrics & Gynaecology, University of Newcastle, New South Wales, Australia.
3
Consultant in Obstetrics, John Hunter Hospital, Newcastle, NSW, Australia.
4
Professor of Obstetrics and Gynecology, University of Siena, Policlinico S. Maria alle Scotte, Viale Bracci,
53100 Siena, Italy.
5
Professor of Endocrinology, Director of Mother and Baby Unit, Hunter medical research Institute, Newcastle, New South
Wales, Australia.
Correspondence at: [email protected] or [email protected]
Abstract
Postterm pregnancy is a pregnancy that extends to 42 weeks of gestation or beyond. Fetal, neonatal and maternal
complications associated with this condition have always been underestimated. It is not well understood why some
women become postterm although in obesity, hormonal and genetic factors have been implicated. The management
of postterm pregnancy constitutes a challenge to clinicians; knowing who to induce, who will respond to induction
and who will require a caesarean section (CS). The current definition and management of postterm pregnancy have
been challenged in several studies as the emerging evidence demonstrates that the incidence of complications
associated with postterm pregnancy also increase prior to 42 weeks of gestation. For example the incidence of stillbirth increases from 39 weeks onwards with a sharp rise after 40 weeks of gestation. Induction of labour before
42 weeks of gestation has the potential to prevent these complications; however, both patients and clinicians alike
are concerned about risks associated with induction of labour such as failure of induction and increases in CS rates.
There is a strong body of evidence however that demonstrates that induction of labour at term and prior to
42 weeks of gestation (particularly between 40 & 42 weeks) is associated with a reduction in perinatal complications
without an associated increase in CS rates. It seems therefore that a policy of induction of labour at 41 weeks in
postterm women could be beneficial with potential improvement in perinatal outcome and a reduction in maternal
complications.
Key words: Body mass index, induction of labour, perinatal complications, postterm pregnancy, ultrasound.
Introduction
Post term pregnancy is associated with an increased
risk of fetal and neonatal mortality and morbidity
(Olesen et al., 2003a;2003b) as well as an increased
maternal morbidity (Caughey et al., 2007). antepartum stillbirth at and beyond term (37-43 weeks
gestation) is a major public health problem accounting for a greater contribution to perinatal mortality
than either deaths from complications of prematurity
or the sudden infant death syndrome (Cotzias et al.,
1999). increased fetal mortality from postterm pregnancy could therefore be prevented by induction of
labour (iOl) at term, however, both clinicians and
patients alike are concerned about the risks of induc-
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14 days (ACOG, 2004). The terms prolonged pregnancy, postdates and postdatism are synonymously
used to describe the same condition. The terms postdate and prolonged pregnancy are ill-defined and
best avoided (ACOG, 2004).
Postmaturity, postmaturity syndrome and dysmaturity are not synonymous terms to postterm pregnancy. They are often used to describe the features
of a neonate who appears to have been in utero
longer than 42 weeks of gestation. They describe the
effects of intrauterine growth restriction (IUGR)
secondary to utero-placental insufficiency encountered in a postterm pregnancy (Shime et al., 1986).
Epidemiology
The incidence of postterm pregnancy is about 7% of
all pregnancies (Martin et al., 2007). The prevalence
varies depending on population characteristics and
local management practices. Population characteristics that affect the prevalence include: the percentage
of primigravidas in the studied population, the prevalence of obesity, a prior postterm pregnancy as
well as genetic predisposition. The proportion of
women with pregnancy complications and the frequency of spontaneous preterm labour also influence
the rate of postterm pregnancy. The link between
ethnicity and overall duration of pregnancy is not
well established (Collins et al., 2001; Caughey et al.,
2009).
Local management practices such as scheduled
IOL, differences in the use of early ultrasound (US)
for pregnancy dating, and elective Caesarean section
(CS) rates will affect the overall prevalence of postterm pregnancy. In the United States for example,
the increase in the incidence of IOL in the last
decade was associated with a drop in the number of
pregnancies continued beyond 41 and 42 weeks
from 18%&10% respectively in 1998 (Ventura et al.,
1998) to 14%& 4% respectively in 2005 (Martin et
al., 2005). Similarly, the use of early US for pregnancy dating has been associated with a significant
reduction in the incidence of postterm pregnancy
from 12% to 3% (Savitz et al., 2002).
Aetiology and risk factors
The most common cause of prolonged pregnancies
is inaccurate dating (Neilson, 2000; Crowley, 2004).
The use of standard clinical criteria to determine the
estimated delivery date (EDD) tends to overestimate
gestational age and consequently increases the incidence of postterm pregnancy (Gardosi et al., 1997;
Taipale and Hiilermaa, 2001). Clinical criteria which
are commonly used to confirm gestational age include last menstrual period (LMP), the size of the
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CRH can directly stimulate fetal adrenal production of dHeas, the precursor for placental oestriol
synthesis (Smith et al., 1998). Maternal plasma CRH
concentrations correlate with oestriol concentrations
(Smith et al., 2009). the rising oestriol driven by
CRH increases at the end of gestation more rapidly
than oestradiol levels leading to an increase in the
oestriol to oestradiol ratio which has been postulated
to produce an estrogenic environment in the last
weeks of pregnancy. Concurrently the rise in maternal plasma progesterone concentrations that occurs
across gestation slows at the end of pregnancy or
even falls. this may be due to CRH inhibition of
placental progesterone synthesis (yang et al., 2006).
thus the pro-pregnancy effect of progesterone
(promoting relaxation) is declining as the pro-labour
actions of oestriol (promoting contraction) are increasing. these changes in ratios have been observed
in preterm births, singletons delivering at term and
in twin gestations (Smith et al., 2009). the situation
in postterm pregnancies is unknown. it is likely to
be similar in postterm women who go into spontaneous labour or those who respond to iOl, based on one
study of postterm women (torricelli et al., 2011).
Complications of postterm pregnancies
Postterm pregnancies are associated with increased
fetal and neonatal motality and morbidity as well as
maternal morbidity. these risks are greater than it
was originally thought. Risks have been underestimated in the past for two reasons. First, earlier
studies on postterm pregnancy were published before
the routine use of ultrasound for pregnancy dating.
as a result many pregnancies included in the studies
were not actually postterm. the second reason rests
within the definition of stillbirth itself. Stillbirth rates
were traditionally calculated using pregnancies delivered at a given gestational age rather than ongoing
(undelivered) pregnancies. this would lower the stillbirth rates in postterm pregnancies as once the fetus
is delivered it is no longer at risk of intra-uterine fetal
death (iuFd). the appropriate denominator is therefore not all deliveries at a given gestational age but
ongoing (undelivered) pregnancies (Rand et al., 2000;
Smith, 2001; Caughey et al., 2003).
One retrospective study of over 170,000 singleton
births, using the appropriate denominator demonstrated a 6-fold increase in stillbirth rates in postterm
pregnancies from 0.35 to 2.12 per 1000 ongoing
pregnancies (Hilder et al., 1998).
Fetal and neonatal complications
the perinatal mortality rate, defined as stillbirths
plus early neonatal deaths, at 42 weeks of gestation
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Stillbirth
neonatal death
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and improve fetal, neonatal and/or maternal outcomes. at 41-42 weeks of gestation it seems that the
risks of iOl are outweighed by the benefits and it is
a common practice to offer iOl to such patients
(Caughey et al., 2008b).
Induction of labour in women with a unfavourable cervix
as many as 80% of women who reach 42 weeks
gestation have an unfavourable cervix (bishop Score
< 6). using cervical ripening prior to induction in
these cases appears to have some advantage in terms
of outcome regardless of parity or method of induction. Pre-induction cervical ripening has resulted in
fewer failed inductions, reduced fetal and maternal
morbidity, reduced medical cost, and possibly a
reduced rate of caesarean delivery in the general
obstetric population (Xenakis et al., 1997; Poma,
1999; Sanchez-Ramos et al., 2002).
Cochrane systematic reviews demonstrated that
prostaglandins (PGs) improve cervical ripeness and
could initiate uterine contractions (boulvain et al.,
2007; Kelly et al., 2009). However, their value in
reducing induction-delivery interval and CS rate in
postterm women is debatable (Rayburn et al., 1988;
Papageorgiou et al., 1992; Sawai et al., 1994).
although multiple studies have used PG to induce
labour in postterm pregnancies, no standardized dose
or dosing interval has been established. Overall, the
medications were well tolerated with few reported
side effects. Higher doses of PG (especially PGe1)
have been associated with an increased risk of
uterine tachysystole and hyper-stimulation leading
to non-reassuring fetal testing results (How et al.,
2001). as such lower doses (e.g. 25 microgram
intravaginal misoprostol) are preferable to 50 microgram (Sanchez-Ramos et al., 2002). When PG is
used, fetal heart rate monitoring should be performed
routinely to assess fetal well-being because of the
risk of uterine hyper-stimulation.
although postterm pregnancy is defined as a
pregnancy of 42 weeks or more of gestation, several
large multi-centre randomized studies of management of pregnancy beyond 40 weeks of gestation
reported favourable outcomes with routine iOl as
early as the beginning of 41 weeks of gestation
(Hannah et al., 1992; niCHHd, 1994; Crowley,
2004). the largest study to date randomly assigned
3,407 low-risk women with uncomplicated singleton
pregnancies at 41 weeks of gestation to labour
induction (with or without cervical ripening agents)
within 4 days of randomization or expectant
management until 44 weeks of gestation (Hannah et
al., 1992). elective induction resulted in a lower
caesarean delivery rate (21.2% versus 24.5%),
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perinatal mortality. these risks were originally underestimated because of inaccurate pregnancy dating
and the denominator used to define stillbirth. the use
of routine ultrasound for dating in the first trimester
has decreased the overall rate of postterm pregnancy
and demonstrated higher complication rates in postterm pregnancies due to better distinction between
term and postterm gestation. also the use of ongoing
pregnancies as a denominator for stillbirth rather than
pregnancies delivered has shown a six-fold increase
in perinatal complications in postterm women.
Forty two weeks of gestation does not represent a
threshold under which risks are uniformly distributed, and there is emerging evidence that fetal,
neonatal and maternal complications do increase
before 42 weeks (from 38-39 weeks onwards with
an obvious rise after 40&41 weeks gestation).
therefore the definition and management of postterm pregnancy have been challenged in several
studies in recent years. in the light of the current
evidence earlier intervention with iOl at 41 weeks
appears appropriate management.
We conclude that in the light of the current
evidence iOl at 41 weeks is justified to minimise
both fetal and maternal complications.
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