Significant effects on neonatal morbidity and mortality after regional change in management of post-term pregnancy.

OBJECTIVE: To evaluate the effects on neonatal morbidity of a regional change in induction policy for post-term pregnancy from 43(+0) to 42(+0) gestational weeks (GWs). DESIGN AND SETTING: Nationwide retrospective register study between 2000 and 2007. POPULATION: All singleton pregnancies with a gestational age of >41(+2) GW (n= 119,198). METHODS: All Swedish counties were divided into three groups where study group allocation was designated by the proportion of pregnancies >42(+2) GW among all pregnancies of >41(+2) GW. Stockholm county formed a separate group. MAIN OUTCOME MEASURES: Perinatal morbidity. RESULTS: In counties with the most active management, 19% of pregnancies >41(+2) GW were delivered at >42(+2) GW during 2000-2004 compared to 7.1% in 2005-2007. In the least active counties, corresponding figures were 21.0% compared to 19.4%. During 2005-2007, the odds ratios for meconium aspiration and 5-minute Apgar score of ≤6 in the least compared to most active counties, were 1.55 (95% CI: 1.03-2.33) and 1.26 (95% CI: 1.06-1.51). In Stockholm >42(+2) GW seen among pregnancies of >41(+2) decreased from 21.0% in 2000-2004 to 5.9% in 2005-2007. Reduced perinatal death risks by 48%, meconium aspiration of 51% and low Apgar scores by 31% in 2005-2007 compared with 2000-2004 were observed. Rates of operative deliveries at >41(+2) GW in Stockholm were unaltered. CONCLUSION: A significant reduction in perinatal morbidity was found, with no influence on operative delivery rates for post-term pregnancy in Stockholm. We advocate a nationwide change toward more active management of post-term pregnancies.

Induction of labor versus expectant management for post-date pregnancy: is there sufficient evidence for a change in clinical practice?

OBJECTIVES: To compare perinatal and maternal outcomes between elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond. DESIGN: Systematic review and meta-analysis. METHODS: We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE) and PsycINFO (1980 to November, 2007). Inclusion criteria were systematic reviews and randomized controlled trials comparing elective induction of labor versus expectant management of pregnancies at 41 weeks and beyond. Three or more reviewers independently read and evaluated all selected studies. Data were extracted and analyzed using Review Manager Software. MAIN OUTCOME MEASURES: Perinatal mortality. RESULTS: Thirteen trials fulfilled the inclusion criteria for the meta-analysis. Elective induction of labor was not associated with lower risk of perinatal mortality compared to expectant management (relative risks (RR): 0.33; 95% confidence intervals (CI): 0.10-1.09). Elective induction was associated with a significantly lower rate of meconium aspiration syndrome (RR: 0.43; 95% CI: 0.23-0.79). More women randomized to expectant management were delivered by cesarean section (RR: 0.87; 95% CI: 0.80-0.96). CONCLUSIONS: The meta-analysis illustrated a problem with rare outcomes such as perinatal mortality. No individual study with adequate sample size has been published, nor would a meta-analysis based on the current literature be sufficient. The optimal management of pregnancies at 41 weeks and beyond is thus unknown.

[Management of postterm pregnancies]. / Prise en charge du dépassement de terme.

The classic pregnancy term is between 37 and 42 weeks of gestation and the perinatal mortality and morbidity rates increasing progressively during this period, it is difficult to decide of an "ideal" term above which a medical intervention (induction of labour) brings more benefits than risks linked to the natural evolution of pregnancy. There is a good scientific evidence for the induction of labour from 41 weeks of gestation, defined like "postdating" term, when the cervical conditions are favourable (Bishop score>5) and systematically from 42 weeks (significative reduction of perinatal mortality rate and not increased rate of cesarean delivery compared with expectant management). An intensive antenatal surveillance involving a nonstress test and an evaluation of amniotic fluid volume is an efficient alternative when the conditions of delivery are unfavourable between 41 and 42 weeks of gestation or when the woman does not wish induction.

Two cases of postmaturity-related perinatal mortality in non-local expectant mothers.

We present two cases of postmaturity-related perinatal mortality with delivery at 42 weeks 6 days' and 44 weeks' gestation, respectively. No cause beyond postmaturity was found. Neither induction of labour nor foetal monitoring had been performed despite these gestations going post 41 weeks because of a current 'social obstetrics' phenomenon--non-local expectant mothers coming to Hong Kong from mainland China for delivery.

Induction at 41 weeks increases the risk of caesarean section in a hospital with a low rate of caesarean sections.

OBJECTIVE: To analyse the impact of a change in the management of prolonged pregnancies from inducing labour at 42(+0) to induction at 41(0-6). DESIGN: Retrospective cohort study. METHODS: Analysis of 3563 single pregnancies with cephalic presentation of ≥ 41 weeks of gestation delivered in Cruces University Hospital (Spain). Two cohorts were compared corresponding to before and after the change in the policy on induction. MAIN OUTCOME MEASURES: Induction rate, vaginal delivery rate, newborn morbidity and mortality. RESULTS: The overall rate of caesarean sections in the patients included in the study was 12.8% (19.5% among those induced and 8.4% among those in whom the onset of labour has been spontaneous). The caesarean section rate in cohorts 41(0-6) and 42(+0) were 14.1% and 11.4%, respectively (p=0.01). Though there were more newborns with umbilical cord blood ph<7.10 in cohort 41(0-6) than in the other group (8.7% versus 4.5%; p<0.01), no significant differences were found between cohorts in 5-min Apgar score < 7, number of admissions to the neonatal care unit or perinatal mortality. CONCLUSION: The induction of labour during week 41 in prolonged pregnancies may increase the rate of caesarean sections in hospitals with low rates of caesarean sections.

[Fetal and neonatal complications related to prolonged pregnancy]. / Complications fœtales et néonatales des grossesses prolongées.

OBJECTIVE: To evaluate fetal and neonatal outcomes related to prolonged pregnancy. METHODS: This study is based on Pubmed search, Cochrane library and HAS recommendations. RESULTS: The risk of fetal complications including macrosomia (6 %), oligohydramnios (10 %-15 %), abnormal fetal heart rate pattern and meconium-stained fluid is increased in prolonged pregnancy (≥ 41(+0) weeks). The rate of stillbirth was estimated between 1.6 ‰ and 3.0 ‰ live births according to countries in post-term pregnancies (≥ 42(+0) weeks). The risk of umbilical cord pH less than 7.10, Apgar score at five minutes inferior to 7, ICU admissions and perinatal asphyxia is increased in post-term infants (≥ 42(+0) weeks) compared with term infants. The risk of neurologic complications including neonatal convulsion, hypoxic ischemic encephalopathy, cerebral palsy, developmental deviations and epilepsy in childhood is increased in post-term infants. The risk of meconium aspiration syndrome, neonatal sepsis, and birth trauma including shoulder dystocia and bone fracture is increased in post-term infants. The rate of perinatal mortality increases in post-term infants. The perinatal mortality in post-term infants could be explained by perinatal asphyxia and meconium aspiration syndrome. CONCLUSIONS: The risk of perinatal complications and mortality are increased in prolonged pregnancy.

Pregnancy risk increases from 41 weeks of gestation.

BACKGROUND: The aim of this study was to evaluate the mortality and morbidity of conservatively managed post-term pregnancies (gestation 294 days and beyond). MATERIALS AND METHODS: This is a population-based prospective study. The sample was comprised of all women (N=17,493) with a singleton pregnancy in one Norwegian county from 1989 to 1999, with a second-trimester ultrasound examination and delivery after 37 completed gestational weeks. RESULTS: One thousand three hundred and thirty-six (7.6%) of the deliveries were post-term. In this group, the increase in perinatal mortality reached borderline significance [relative risk (RR) 2.0; 95% confidence interval 0.9-4.6]. Perinatal morbidity expressed as Apgar score <7 at 5 min (RR 2.0; 95% confidence interval 1.2-3.3), and transferal to neonatal intensive care unit (RR 1.6; 95% confidence interval 1.3-2.0) were significantly more frequent. However, RR for perinatal death calculated per 1000 ongoing pregnancies increased significantly from 0.2 in week 37-3.7 in week 42, using perinatal mortality in gestational week 41 as a reference. CONCLUSIONS: Our results indicate that expectant management of post-term pregnancies allowing pregnancies to continue up to week 43 carries a risk for perinatal mortality and morbidity. The risk increases already from gestational week 41. The guidelines for management of post-term pregnancies should be revised.