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Postterm pregnancy
Author: Errol R Norwitz, MD, PhD, MBA
Section Editor: Charles J Lockwood, MD, MHCM
Deputy Editor: Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2019. | This topic last updated: Feb 07, 2019.

INTRODUCTION

The timely onset of labor and delivery is an important determinant of perinatal outcome. Although
it has long been known that there is a small absolute increase in perinatal mortality as
pregnancies extend beyond the estimated due date, the optimum gestational age for beginning
formal fetal monitoring (eg, nonstress test, biophysical profile) and the optimum gestational age for
intervention rather than continued formal fetal monitoring has been more controversial.

This topic will discuss maternal and fetal issues related to postterm pregnancies. Issues related to
the postterm infant are reviewed separately. (See "Postterm infant".)

DEFINITIONS

The following definitions describe the subgroups of term pregnancy [1,2]:

● Postterm – ≥42+0 weeks of gestation (ie, ≥294 days from the first day of the last menstrual
period and ≥14 days from the estimated day of delivery)

● Late term – 41+0 to 41+6 weeks of gestation

● Full term – 39+0 to 40+6 weeks of gestation

● Early term – 37+0 to 38+6 weeks of gestation

PREVALENCE

In the United States, birth certificate data indicate that 0.33 percent of pregnancies deliver at ≥42
weeks and 6.25 percent deliver at 41 weeks [3]. A study of birth rates ≥42 weeks in 13 European
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countries observed a wide range across the continent: from 0.4 and 0.6 percent in Austria and
Belgium to 7.5 and 8.1 percent in Sweden and Denmark [4]. Variations in prevalence are likely due
to the factors discussed below.

One of the most important factors impacting prevalence of postterm pregnancy is whether early
ultrasound assessment of gestational age is performed routinely, as this tends to reduce the
prevalence compared with menstrual dating. In a meta-analysis that compared the rate of labor
induction for postterm pregnancy in women who underwent routine sonographic estimation of their
delivery date before 24 weeks of gestation with the rate in women whose estimated delivery date
was calculated from their last menstrual period, early routine ultrasound examination reduced the
rate of intervention for postterm pregnancy by 40 percent (18/1000 versus 31/1000; odds ratio
0.59, 95% CI 0.42-0.83; eight trials, n = 25,516), although the evidence was of low quality because
of heterogeneity and design limitations [5].

Other factors that affect the prevalence of postterm pregnancy in a population include the
prevalence of primigravid women, which shifts the gestational age at birth curve to the right since
they are more likely to deliver postterm. Factors that shift the gestational age at birth curve to the
left include a high prevalence of spontaneous preterm birth and/or women with pregnancy
complications leading to indicated preterm birth, and local practice patterns such as a high rate of
planned cesarean delivery and/or elective labor induction at term.

ETIOLOGY

● The majority of postterm pregnancies have no known etiology.

● One-third to one-half of the variation in postterm birth in a population can be attributed to

maternal or fetal genetic influence on the initiation of parturition [6].

● In rare cases, postterm pregnancy has been attributed to defects in fetal production of
hormones involved in parturition [7] (see "Physiology of parturition"). For example, fetal
disorders associated with placental sulfatase deficiency (eg, X-linked ichthyosis) result in
extremely low estriol levels and other hormonal changes compared with normal pregnancies.
The mean duration of pregnancies with placental sulfatase deficiency appears to be one week
longer than pregnancies without this disorder, although most such pregnancies still deliver
before 42 weeks of gestation [8,9].

Anencephaly, which results in absence or hypoplasia of the hypothalamus and pituitary and
adrenal hypoplasia, often results in postterm pregnancy when polyhydramnios is absent
(mean gestational age at delivery: 311 days with no polyhydramnios versus 253 days with
polyhydramnios [10]). Since pregnancies with anencephaly are now routinely detected
antepartum and terminated or induced, postterm duration is no longer observed.

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RISK FACTORS

Women at highest risk (relative risk ≥2) of postterm pregnancy are those with a previous postterm
pregnancy. (See 'Recurrence risk' below.)

Additional, more modest risk factors (relative risk <2) include [6,11-18]:

● Nulliparity
● Male fetus
● Obesity
● Older maternal age
● Maternal (and to a lesser extent paternal) personal history of postterm birth
● Maternal race/ethnicity (non-Hispanic white women are at higher risk than African-American,
Hispanic, and Asian women)

DIAGNOSIS

The diagnosis of pregnancy ≥42+0 weeks of gestation is based on the clinician's most accurate
estimate of the patient's delivery date (EDD).

The EDD is based on an ultrasound examination performed before 22+0 weeks of gestation if the
ultrasound-based EDD differs from that calculated from menstrual dating (LMP) by more than five
to seven days, as described in the table (table 1). If the ultrasound-based EDD is within five to
seven days of the LMP-based EDD, then LMP is used to determine EDD. Exceptions to this
approach include pregnancies with known dates of conception/implantation, such as in
pregnancies conceived by in vitro fertilization. (See "Prenatal assessment of gestational age, date
of delivery, and fetal weight".)

MORBIDITY AND MORTALITY

Postterm pregnancy is associated with maternal, fetal, and neonatal complications. Many of the
complications are sequelae of either excessive fetal growth or placental insufficiency.

Macrosomia — Because of the longer duration of intrauterine growth, postterm fetuses tend to be
larger than term fetuses, and have a higher incidence of macrosomia (≥4500 grams: 2.5 to 10
percent postterm versus 0.8 to 1 percent at term), [19-21].

Macrosomia increases the risks for several adverse sequelae, including abnormal labor
progression, cesarean delivery, assisted vaginal delivery, shoulder dystocia,
maternal/fetal/newborn birth injury, postpartum hemorrhage, and neonatal metabolic problems.
(See "Fetal macrosomia", section on 'Significance'.)
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Dysmaturity — Not all postterm fetuses continue to grow along a normal growth trajectory. Up to
20 percent of postterm fetuses have "fetal dysmaturity (postmaturity) syndrome", a term used to
describe fetuses with characteristics of chronic intrauterine malnutrition [22-24]. These fetuses are
at increased risk of umbilical cord compression due to oligohydramnios, and abnormal antepartum
or intrapartum fetal heart rate patterns due to placental insufficiency or cord compression.
Meconium passage is common and may be related to physiological maturation of the gut, fetal
hypoxia, or both.

Dysmature neonates have a long thin body, long nails, and are small for gestational age. Their
skin is dry (vernix caseosa is decreased or absent), meconium-stained, parchment-like, and
peeling; it appears loose, especially over the thighs and buttocks, and has prominent creases;
lanugo hair is sparse or absent, while scalp hair is increased. These neonates are at risk for
morbidities associated with growth restriction, including hypoglycemia, polycythemia, perinatal
asphyxia, meconium aspiration, and persistent pulmonary hypertension. They are also at risk for
neurodevelopmental complications (eg, seizures, cerebral palsy). (See "Postterm infant".)

Perinatal mortality — The perinatal mortality rate at ≥42 weeks of gestation is twice the rate at
term, increasing fourfold at 43 weeks, and five- to sevenfold at 44 weeks [25-29]. Neonates born
at ≥41 weeks of gestation experience a one-third greater risk of neonatal mortality than term
neonates born at 38 to 40 weeks of gestation [30].

However, the absolute rate of fetal or neonatal death is low. In large studies from the United
Kingdom, the rate of antepartum fetal death was [31]:

● 40 to 41 weeks – 0.86 to 1.08 per 1000 ongoing pregnancies

● 41 to 42 weeks – 1.2 to 1.27 per 1000 ongoing pregnancies
● 42 to 43 weeks – 1.3 to 1.9 per 1000 ongoing pregnancies
● >43 weeks – 1.58 to 6.3 per 1000 ongoing pregnancies

Perinatal mortality increases as pregnancy extends beyond full term, particularly after 41 weeks,
due to increases in both nonanomalous stillbirths and early neonatal deaths [30,32-35].
Intrauterine infection, placental insufficiency due to placental aging, and cord compression leading
to fetal hypoxia, asphyxia, and meconium aspiration are thought to contribute to the excess
perinatal deaths [28,36,37].

It is unclear whether, or to what degree, perinatal mortality is increased in postterm pregnancies

without fetal malformations, signs of placental insufficiency (growth restriction, oligohydramnios),
or maternal disorders associated with adverse pregnancy outcome (eg, diabetes, hypertension)
[38-41]. In a pooled analysis, two perinatal deaths occurred among 3914 such pregnancies after
42 weeks of gestation (0.05 percent), and data were available for only 238 such pregnancies over
43 weeks [42]. (See "Postterm infant", section on 'Perinatal mortality'.)

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MANAGEMENT

The following discussion refers to the singleton, cephalic fetus of an otherwise uncomplicated
pregnancy that reaches 41+0 weeks of gestation. Multiple gestations, noncephalic presentations,
and pregnancies with medical or obstetric complications are generally delivered before 41 weeks
(refer to individual topic reviews on each subject).

Pregnancies that reach 41+0 weeks of gestation can be induced or managed expectantly with
ongoing fetal assessment and intervention if spontaneous labor does not occur by a predefined
gestational age or fetal assessment is not reassuring. In the low-risk postterm gravida, both of
these approaches are associated with low absolute rates of adverse outcome [43]. Patients should
be counseled about what these approaches involve (labor induction with/without cervical ripening
agents, type and frequency of antepartum fetal and maternal monitoring) and the maternal and
fetal benefits and risks of both approaches.

Our approach: Induction at 41+0 — We favor induction of postterm pregnancies at or shortly

after 41+0 weeks of gestation irrespective of cervical status, given that intervention at this time
reduces perinatal mortality without increasing perinatal morbidity, and reduces cesarean delivery
rates. (See 'Evidence' below.)

We generally administer a cervical ripening agent (eg, prostaglandin, balloon catheter) to women
with unfavorable cervixes. (See "Techniques for ripening the unfavorable cervix prior to
induction".)

This approach is in general agreement with professional guidelines that suggest routine induction
between 41+0 and 42+0 weeks of gestation, with the exact timing during this week determined by
clinician and patient preferences and local circumstances [44]. The American College of
Obstetricians and Gynecologists recommends induction of labor after 42+0 weeks and by 42+6
weeks, but considers induction at 41+0 to 42+0 weeks reasonable [45].

For women who want to avoid standard cervical ripening agents and/or induction, membrane
stripping (also called sweeping) reduces the proportion of patients who remain undelivered at 42
weeks [46]. The optimum time to initiate membrane stripping/sweeping and the frequency (one
time versus on multiple days) has not been studied in randomized trials, but beginning any time
after 39+0 weeks of gestation is reasonable. (See "Induction of labor with oxytocin", section on
'Membrane stripping'.)

Evidence — The following lines of evidence support our approach, which reduces perinatal
mortality and meconium aspiration syndrome, reduces the cesarean delivery rate, and is
satisfactory to most patients.

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● In a 2018 meta-analysis of randomized trials comparing labor induction with expectant

management of pregnancies at or beyond term (30 trials; over 12,000 women), routine
induction resulted in [43]:

• 70 percent reduction in perinatal mortality (2/4988 versus 16/4972; relative risk [RR] 0.33,
95% CI 0.14-0.78; moderate quality of evidence). Subgroup analysis showed similar
reductions in perinatal mortality at ≥41 weeks (2/4217 versus 13/4191; RR 0.33, 95% CI
0.13-0.87) and before 41 weeks (0/771 versus 3/781; RR 0.33, 95% CI 0.05-2.06); tests
for interaction did not reveal a significant difference in treatment effect between
subgroups.

• 70 percent reduction in stillbirth (1/4988 versus 10/4972; RR 0.33, 95% CI 0.11-0.96;

moderate quality of evidence). In subgroup analysis of pregnancies induced at <41
weeks and ≥41 weeks, the risk reduction was similar, but the confidence intervals were
wide (<41 weeks: 0.05-2.06; ≥41 weeks: 0.09-1.24).

• 8 percent reduction in cesarean delivery (169/1000 versus 184/1000; RR 0.92, 95% CI

0.85-0.99; moderate quality evidence). Tests for interaction were not significant,
suggesting that the reduction in cesarean delivery was not dependent on timing of
induction before versus ≥41 weeks.

• 28 percent reduction in macrosomia (greater than 4000 g) (RR 0.72, 95% CI 0.54-0.96).

• 23 percent reduction in meconium aspiration syndrome (RR 0.77, 95% CI 0.62-0.96).

• 12 percent trend in reduction in NICU admission (75/1000 versus 85/1000; RR 0.88, 95%
CI 0.77-1.01).

A small number of trials included other important outcomes and reported similar risks for
neonatal trauma, birth asphyxia, neonatal convulsions, perineal trauma, and postpartum
hemorrhage with both approaches, but this evidence was generally of low quality. No trials
reported on neonatal encephalopathy or neurodevelopmental outcome in childhood.

● In a large study of fetal and neonatal mortality rates in over 650,000 nonanomalous singleton
pregnancies at 37 to 44 weeks of gestation in the National Swedish Medical Birth Registry,
the rate of fetal demise was significantly higher than the rate of neonatal death at any
gestational age ≥40+3 weeks of gestation when fetal mortality was based on the number of
fetal deaths per 1000 ongoing pregnancies rather than per 1000 deliveries [47].

Alternative approach: Expectant management with fetal monitoring — Expectant

management is the alternative to induction. Expectantly managed pregnancies typically undergo
twice-weekly fetal assessment beginning at 41+0 weeks (or shortly thereafter), with intervention if
spontaneous labor does not begin by a predefined gestational age or fetal assessment testing is
abnormal [48,49]. Either a nonstress test plus assessment of amniotic fluid volume or the
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biophysical profile can be used for antenatal monitoring; there is no convincing evidence that one
method is superior to the other [50].

Expectant management with fetal monitoring is not unreasonable for several reasons [43]:

● The absolute rate of perinatal death is relatively low at ≥41 weeks and not much higher in
absolute terms with expectant management than with induction: approximately 3 perinatal
deaths/1000 pregnancies with expectant management versus 0.5 perinatal deaths/1000 with
labor induction.

● A relatively high number of inductions (over 400) would need to be performed to prevent one
perinatal death.

● Some women place a high value on going into labor spontaneously.

Fetal monitoring — Postterm pregnancy is a universally accepted indication for antenatal fetal
monitoring because of the increased risk of antepartum fetal demise with advancing gestational
age. However, the efficacy of antenatal fetal assessment for preventing unexplained fetal demise
in postterm fetuses has not been validated by appropriately sized and placebo-controlled
randomized trials, and probably never will be evaluated in this way because of ethical and
medicolegal concerns of assigning some pregnancies to an unmonitored group. The optimal type
and frequency of fetal testing, and the gestational age for beginning monitoring, have not been
determined. Case-control studies support initiating twice weekly antepartum fetal surveillance
between 41+0 and 42+0 weeks of gestation [48,49]. Twice weekly amniotic fluid volume
assessment is important because amniotic fluid can become severely reduced within 24 to 48
hours [51]. (See "Oligohydramnios" and "Overview of antepartum fetal surveillance", section on
'Fetal assessment techniques'.)

It is clear that monitoring the postterm fetus with Doppler ultrasonography of the umbilical artery
has no proven benefit [52-54]. Evaluation of pulsatility indices of the uterine arteries, middle
cerebral artery, descending aorta, ductus venosus, and inferior vena cava is also not useful [54].

Timing of delivery in expectantly managed pregnancies — We agree with the American

College of Obstetricians and Gynecologists recommendation to induce labor by 42+6 weeks of
gestation in all pregnancies [45]. Earlier induction is indicated for development of any of the usual
obstetrical indications, including evidence of oligohydramnios [55,56]. Adverse pregnancy
outcomes (abnormal fetal heart rate tracing, neonatal intensive care unit admission, low Apgar)
are more likely when oligohydramnios is present [55-60]. (See "Oligohydramnios".)

Because so few pregnancies reach 43 weeks, there is no strong evidence on which to base a
recommendation for the maximum gestational age at which an otherwise uncomplicated
pregnancy should be delivered in the absence of standard maternal or fetal indications or
spontaneous labor.

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RECURRENCE RISK

After one postterm pregnancy, the risk of a second postterm birth is increased two- to fourfold; the
risk of recurrence is even higher after two prior postterm pregnancies [11,12,61,62].

As an example, in the Netherlands Perinatal Registry database of over 230,000 women with
singleton pregnancies who delivered their first pregnancy at 37+0 to 42+6 weeks of gestation and
had a subsequent singleton pregnancy, postterm births occurred in 7.7 percent of first
pregnancies, 15 percent of second pregnancies in women who had a previous postterm birth, and
in 4 percent of second pregnancies in women who had a previous term birth [62].

PREVENTION

As discussed above, early routine ultrasound examination reduces the rate of intervention for
postterm pregnancy by approximately 40 percent [5]. (See 'Prevalence' above.)

Membrane sweeping at term can initiate labor and thus prevent postterm pregnancy. (See 'Our
approach: Induction at 41+0' above and "Induction of labor with oxytocin", section on 'Membrane
stripping'.)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: When your baby is overdue (The Basics)")

● Beyond the Basics topics (see "Patient education: Postterm pregnancy (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

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● Postterm pregnancy refers to a pregnancy that is ≥42+0 weeks of gestation or 294 days from
the first day of the last menstrual period (LMP). (See 'Definitions' above.)

● The diagnosis of postterm pregnancy is based on the clinician's most accurate estimate of the
patient's delivery date, which is based on LMP for some patients and on ultrasound dating for
others (table 1). (See 'Diagnosis' above.)

● In pregnancies dated by first-trimester ultrasound examination, the prevalence of postterm

pregnancy is approximately 2 percent and fewer inductions are performed for postterm
pregnancy than in pregnancies dated by LMP. (See 'Prevalence' above.)

● Women at highest risk of postterm pregnancy are those with a previous postterm pregnancy.
The risk of a second postterm pregnancy is increased two- to fourfold and is even higher after
two prior postterm pregnancies. (See 'Risk factors' above and 'Recurrence risk' above.)

● Many of the maternal, fetal, and neonatal complications of postterm pregnancy are sequelae
of either excessive fetal growth (macrosomia) or placental insufficiency (fetal/neonatal
dysmaturity, growth restriction, oligohydramnios). (See 'Macrosomia' above and 'Dysmaturity'
above.)

● Perinatal mortality increases with increasing gestational age after 40 weeks of gestation, but
the absolute risk of fetal death is low:

• 40 to 41 weeks – 0.86 to 1.08 per 1000 ongoing pregnancies

• 41 to 42 weeks – 1.2 to 1.27 per 1000 ongoing pregnancies
• 42 to 43 weeks – 1.3 to 1.9 per 1000 ongoing pregnancies
• >43 weeks – 1.58 to 6.3 per 1000 ongoing pregnancies

Intrauterine infection, placental insufficiency or cord compression leading to fetal hypoxia and
asphyxia, and meconium aspiration are thought to contribute to the excess perinatal deaths.
(See 'Perinatal mortality' above.)

● In postterm pregnancies without fetal malformations, signs of placental insufficiency, or

maternal disorders associated with adverse pregnancy outcome (eg, diabetes, hypertension),
it is unclear whether or to what degree perinatal mortality is increased. (See 'Perinatal
mortality' above.)

● For pregnancies that reach 41+0 weeks of gestation, we suggest induction rather than
expectant management (Grade 2B). Induction is associated with lower perinatal mortality
than expectant management and does not increase the risk of cesarean delivery. The
absolute benefits of routine induction are modest, however, and depending on personal
values and preferences, some women may choose to be managed expectantly. (See 'Our
approach: Induction at 41+0' above.)

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● For women at 41+0 weeks who choose expectant management, we monitor fetal well-being
by nonstress testing with amniotic fluid volume assessment or by the biophysical profile, twice
weekly beginning at 41+0 weeks or shortly thereafter. (See 'Alternative approach: Expectant
management with fetal monitoring' above.)

● In expectantly managed pregnancies, we agree with the American College of Obstetricians

and Gynecologists recommendation to induce labor by 42+6 weeks of gestation. Earlier
induction is indicated for development of any of the usual obstetrical indications. (See 'Timing
of delivery in expectantly managed pregnancies' above.)

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Topic 6749 Version 28.0

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GRAPHICS

Reassigning EDD based on date-ultrasound discrepancy

Change LMP-based EDD to ultrasound-

Gestational age (weeks+days) based on based EDD if ultrasound-based
the first day of LMP gestational age differs from LMP-based
gestational age by more than:

≤8+6 5 days

9+0 to 13+6 7 days

14+0 to 15+6 7 days

16+0 to 21+6 10 days

22+0 to 27+6 14 days

≥28+0 21 days

EDD: estimated date of delivery; LMP: last menstrual period.

Data from: American College of Obstetricians and Gynecologists. Committee Opinion No 700: Methods for Estimating the
Due Date. Obstet Gynecol 2017; 129:e150.

Graphic 97246 Version 7.0

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Contributor Disclosures
Errol R Norwitz, MD, PhD, MBA Grant/Research/Clinical Trial Support: Illumina [Preeclampsia (primary
investigator on a prospective cohort study to collect samples from patients with preeclampsia to facilitate
development of a biomarker test to predict/diagnose this disorder)]. Consultant/Advisory Boards: Hologic
[Preterm birth (Fetal fibronectin test to predict preterm birth)]; Natera [Fetal aneuploidy testing (NIPT as a
screening test for fetal aneuploidy)]; Seracare [Fetal aneuploidy testing (Developing controls for NIPT
screening test for fetal aneuploidy)]; Illumina [Minimally invasive genetic testing for fetal and pregnancy-
related disorders]. Patent Holder: Bayer [Prediction test for preeclampsia [Use of urinary angiogenic factors
to predict preeclampsia]. Equity Ownership/Stock Options: 1908 Brands/Bundle Organics [Nutritional
supplements for pregnancy]. Charles J Lockwood, MD, MHCM Nothing to disclose Vanessa A Barss, MD,
FACOG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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