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Postmaturity (Prolonged Pregnancy)
"A pregnancy that exceeds 42 complete weeks (294 days) after last menstrual period(LMP)."
Where possible, first trimester ultrasound rather than LMP dating should be relied on toassess pregnancy duration.
Perinatal risks associated with prolonged pregnancy
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Beyond around 41 weeks placental function may decline and become insufficient,reducing the supply of oxygen and nutrients to the fetus. Placental insufficiencyincreases the risk of intrapartum fetal hypoxia.
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The risk of stillbirth or neonatal death (in healthy women with normal
pregnancies) is greater at 42 weeks than 37 weeks. The risk has been shown to beup to 8 times greater at 43 weeks.
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The risk of Caesarean delivery and maternal complications also increase withgestational age.
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There is increased risk of fetal macrosomia,i.e. birth weight > 4 kg and birth
injury.
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Some fetal anomalies, e.g. anencephaly, are associated with prolonged pregnancy.
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Increased risk of epilepsyin the neonate, particularly if delivered by instrumental
delivery or Caesarean section.
Epidemiology
Approximately 7.5% of pregnancies continue to 42 weeks or beyond.
Postmaturity is asyndrome seen in some infants born at or after 42 weeks. However, the term post-matureis often used to describe any infant born after 42 weeks.
Risk factors
Previous prolonged pregnancy increases risk of recurrence in subsequent pregnanciestwo- to three-fold.
Few pre-natal risk factors are known. However recent work suggests an association with:
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BMI > 35.
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Primigravidity.
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Fish consumption in first 2 trimesters.
Presentation
Symptoms
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When post-mature the neonate has lower than normal amounts of subcutaneousfat and reduced mass of soft tissue.
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The skin may be loose, flaky and dry.
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Fingernails and toenails may be longer than usual and stained yellow frommeconium.
Signs
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Before delivery there may be reduced fetal movement.
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A reduced volume of amniotic fluid may cause a reduction in the size of theuterus.
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Investigations
Women with no other indications for induction, who do not wish labour to be induced,can be offered monitoring to assess placental function and fetal health. There is a lack of evidence with which to assess the benefits of monitoring and the effectiveness of thevarious techniques.
Management
Management of prolonged pregnancy in the absence of other complications iscontroversial:
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The Royal College of Obstetricians and Gynaecologists/NICE guidelinesrecommend that women should be
offered
induction after 41 weeks.
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Women who decline induction should be offered increased antenatal monitoringfrom 42 weeks, consisting of twice-weekly cardiotocography(CTG) and
ultrasound estimation of single deepest amniotic pool. A pool depth of < 8 cmindicates increased intrapartum risk to the fetus.
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If expectant management is used, some sources recommend labour should beinduced at the beginning of the 43rd week.
However, in a recent randomised trial there were no differences between induced (at 289days) and monitored groups (every 3 days) in neonatal morbidity, mode of delivery, andgeneral outcome.
Document references
1. Neilson JP. Ultrasound for fetal assessment in early pregnancy. CochraneDatabase of Systematic Reviews 1998, Issue 4. Art. No.: CD000182. DOI:10.1002/14651858.CD000182.2.Smith GC; Life-table analysis of the risk of perinatal death at term and post termin singleton pregnancies. Am J Obstet Gynecol. 2001 Feb;184(3):489-96.[abstract]3.Hilder L, Costeloe K, Thilaganathan B; Prolonged pregnancy: evaluatinggestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol. 1998Feb;105(2):169-73. [abstract]4.Ehrenstein V, Pedersen L, Holsteen V, et al; Postterm delivery and risk for epilepsy in childhood. Pediatrics. 2007 Mar;119(3):e554-61. [abstract]5.Harrington DJ, MacKenzie IZ, Thompson K, et al; Does a first trimester datingscan using crown rump length measurement reduce the rate of induction of labour for prolonged pregnancy? An uncompleted randomised controlled trial of 463women. BJOG. 2006 Feb;113(2):171-6. [abstract]6.I Mogren, H Stenlund, U Hogberg. Recurrence of prolonged pregnancy.International Journal of Epidemiology, Volume 28, Number 2, pp. 253-257(5);
April
19997.Olesen AW, Westergaard JG, Olsen J; Prenatal risk indicators of a prolonged pregnancy. The Danish Birth Cohort 1998-2001. Acta Obstet Gynecol Scand.2006;85(11):1338-41. [abstract]8.Olsen SF, Osterdal ML, Salvig JD, et al; Duration of pregnancy in relation toseafood intake during early and mid pregnancy: prospective cohort. Eur JEpidemiol. 2006;21(10):749-58. Epub 2006 Nov 17. [abstract]9.Briscoe D, Nguyen H, Mencer M, Gautam N, Kalb DB. Management of Pregnancy Beyond 40 Weeks' Gestation. American Family Physician;
May
200510. NICE(inherited guideline). Induction of labour. July 2008.11.Dasari P, Niveditta G, Raghavan S; The maximal vertical pocket and amnioticfluid index in predicting fetal distress in prolonged pregnancy. Int J GynaecolObstet. 2007 Feb;96(2):89-93. Epub 2007 Jan 22. [abstract]12.Heimstad R, Skogvoll E, Mattsson LA, et al; Induction of labor or serial antenatalfetal monitoring in postterm pregnancy: a randomized controlled trial. ObstetGynecol. 2007 Mar;109(3):609-17. [abstract]
Internet and further reading
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Large PDF.
Acknowledgements
EMIS is grateful to Dr Hayley Willacy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009.
Document ID: 2640Document Version: 21 Document Reference: bgp208
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