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## Complete Summary

#### GUIDELINE TITLE

Management of postterm pregnancy.

#### BIBLIOGRAPHIC SOURCE(S)

American College of Obstetricians and Gynecologists (ACOG). Management
of postterm pregnancy. Washington (DC): American College of
Obstetricians and Gynecologists (ACOG); 2004 Sep. 8 p. (ACOG practice
bulletin; no. 55). \[69 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of
Obstetricians and Gynecologists (ACOG). Management of postterm
pregnancy. Washington (DC): American College of Obstetricians and
Gynecologists; 1997 Oct. 6 p. (ACOG practice patterns; no. 6).

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [April 10, 2006, Mifeprex (mifepristone) and
    misoprostol](http://www.fda.gov/cder/drug/infopage/mifepristone/default.htm):
    Update to March 17, 2006 notice (see below).

-   [March 17, 2006, Mifeprex (mifepristone) and
    misoprostol](http://www.fda.gov/medwatch/safety/2006/safety06.htm#Mifeprex):
    Public Health Advisory to notify healthcare professionals of two
    additional deaths.

-   [July 19, 2005, Mifeprex (mifepristone) and
    misoprostol](http://www.fda.gov/medwatch/safety/2005/safety05.htm#Mifeprex):
    Revised BOXED WARNING and WARNINGS sections of the Prescribing
    Information, the Medication Guide and Patient Agreement to inform
    healthcare professionals of four cases of septic deaths in the
    United States

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Postterm pregnancy

#### GUIDELINE CATEGORY

Management

#### CLINICAL SPECIALTY

Obstetrics and Gynecology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To aid practitioners in making decisions about appropriate obstetric
    and gynecologic care

-   To examine the evidence and provide recommendations about two
    management strategies for postterm pregnancy: antenatal surveillance
    and induction of labor

#### TARGET POPULATION

Pregnant women who have completed 42 weeks of gestation or are 14 days
beyond the estimated delivery date

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Accurate assessment of gestational age (ultrasonographic validation)

2.  Antenatal surveillance (nonstress testing, assessment of amniotic
    fluid volume estimation)

3.  Assessment of cervical condition prior to labor induction

4.  Induction of labor, including use of prostaglandin gels
    (dinoprostone or misoprostol)

5.  Expectant management

#### MAJOR OUTCOMES CONSIDERED

-   Maternal and perinatal morbidity and mortality

-   Duration of labor (induction-to-delivery interval)

-   Cesarean delivery rate among patients managed

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The MEDLINE database, the Cochrane Library, and American College of
Obstetricians and Gynecologists\' own internal resources and documents
were used to conduct a literature search to locate relevant articles
published between January 1985 and April 2004. The search was restricted
to articles published in the English language. Priority was given to
articles reporting results of original research, although review
articles and commentaries also were consulted. Abstracts of research
presented at symposia and scientific conferences were not considered
adequate for inclusion in this document. Guidelines published by
organizations or institutions such as the National Institutes of Health
and the American College of Obstetricians and Gynecologists were
reviewed, and additional studies were located by reviewing
bibliographies of identified articles.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Studies were reviewed and evaluated for quality according to the method
outlined by the U.S. Preventive Services Task Force:

**I**: Evidence obtained from at least one properly designed randomized
controlled trial

**II-1**: Evidence obtained from well-designed controlled trials without
randomization

**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group

**II-3**: Evidence obtained from multiple time series with or without
the intervention. Dramatic results in uncontrolled experiments could
also be regarded as this type of evidence.

**III**: Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees.

#### METHODS USED TO ANALYZE THE EVIDENCE

Review of Published Meta-Analyses\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Analysis of available evidence was given priority in formulating
recommendations. When reliable research was not available, expert
opinions from obstetrician--gynecologists were used. See also the
\"Rating Scheme for the Strength of Recommendations\" field regarding
Grade C recommendations.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Based on the highest level of evidence found in the data,
recommendations are provided and graded according to the following
categories:

**Level A** --- Recommendations are based on good and consistent
scientific evidence.

**Level B** --- Recommendations are based on limited or inconsistent
scientific evidence.

**Level C** --- Recommendations are based primarily on consensus and
expert opinion.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Practice Bulletins are validated by two internal clinical review panels
composed of practicing obstetrician-gynecologists generalists and
sub-specialists. The final guidelines are also reviewed and approved by
the American College of Obstetricians and Gynecologists (ACOG) Executive
Board.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The grades of evidence (I-III) and levels of recommendations (A-C) are
defined at the end of the \"Major Recommendations\" field.

**The following recommendations are based on good and consistent
scientific evidence (Level A)**:

-   Women with postterm gestations who have unfavorable cervices can
    either undergo labor induction or be managed expectantly.

-   Prostaglandin can be used in postterm pregnancies to promote
    cervical ripening and induce labor.

-   Delivery should be effected if there is evidence of fetal compromise
    or oligohydramnios.

**The following recommendations are based primarily on consensus and
expert opinion (Level C)**:

-   Despite a lack of evidence that monitoring improves perinatal
    outcome, it is reasonable to initiate antenatal surveillance of
    postterm pregnancies between 41 weeks (287 days; estimated delivery
    date \[EDD\] +7 days) and 42 weeks (294 days; EDD +14 days) of
    gestation because of evidence that perinatal morbidity and mortality
    increase as gestational age advances.

-   Many practitioners use twice-weekly testing with some evaluation of
    amniotic fluid volume beginning at 41 weeks of gestation. A
    nonstress test and amniotic fluid volume assessment (a modified
    biophysical profile \[BPP\]) should be adequate.

-   Many authorities recommend prompt delivery in a postterm patient
    with a favorable cervix and no other complications.

**Definitions**:

**Grades of Evidence**:

**I**: Evidence obtained from at least 1 properly designed randomized
controlled trial.

**II-1**: Evidence obtained from well-designed controlled trials without
randomization.

**II-2**: Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than 1 center or research group.

**II-3**: Evidence obtained from multiple time series with or without
the intervention. Dramatic results in uncontrolled experiments could
also be regarded as this type of evidence.

**III**: Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert committees.

**Levels of Recommendation**

**Level A** --- Recommendations are based on good and consistent
scientific evidence.

**Level B** --- Recommendations are based on limited or inconsistent
scientific evidence.

**Level C** --- Recommendations are based primarily on consensus and
expert opinion.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate assessment of gestational age and diagnosis of postterm
gestation, as well as recognition and management of risk factors, may
reduce the risk of adverse sequelae. Antenatal surveillance and
induction of labor are 2 widely used strategies that theoretically may
decrease the risk of an adverse fetal outcome.

#### POTENTIAL HARMS

-   Overall, the medications (prostaglandin E~2~ \[PGE~2~;
    dinoprostone\] and PGE~1~ \[misoprostol\]) were well tolerated with
    few reported side effects. Higher doses of PG (especially PGE~1~)
    have been associated with an increased risk of uterine tachysystole
    and hyperstimulation leading to nonreassuring fetal testing results

-   The risk of uterine rupture does not appear to increase
    substantially after 40 weeks of gestation, but the risk appears to
    be increased with labor induction with PG or pitocin regardless of
    gestational age.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

These guidelines should not be construed as dictating an exclusive
course of treatment or procedure. Variations in practice may be
warranted based on the needs of the individual patient, resources, and
limitations unique to the institution or type of practice.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American College of Obstetricians and Gynecologists (ACOG). Management
of postterm pregnancy. Washington (DC): American College of
Obstetricians and Gynecologists (ACOG); 2004 Sep. 8 p. (ACOG practice
bulletin; no. 55). \[69 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1997 Oct (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American College of Obstetricians and Gynecologists - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American College of Obstetricians and Gynecologists

#### GUIDELINE COMMITTEE

American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins-Obstetrics

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Not stated

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American College of
Obstetricians and Gynecologists (ACOG). Management of postterm
pregnancy. Washington (DC): American College of Obstetricians and
Gynecologists; 1997 Oct. 6 p. (ACOG practice patterns; no. 6).

#### GUIDELINE AVAILABILITY

Electronic copies: Not available at this time.

Print copies: Available for purchase from the American College of
Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 4500,
Kearneysville, WV 25430-4500; telephone, 800-762-2264, ext. 192; e-mail:
<sales@acog.org>. The ACOG Bookstore is available online at the [ACOG
Web site](http://www.acog.org/bookstore/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

The following is available:

-   What to expect after your due date. Atlanta (GA): American College
    of Obstetricians and Gynecologists (ACOG); 2006.

Electronic copies: Available from the [American College of Obstetricians
and Gynecologists (ACOG) Web
site](http://www.acog.org/publications/patient_education/bp069.cfm).

Print copies: Available for purchase from the American College of
Obstetricians and Gynecologists (ACOG) Distribution Center, PO Box 4500,
Kearneysville, WV 25430-4500; telephone, 800-762-2264, ext. 192; e-mail:
<sales@acog.org>. The ACOG Bookstore is available online at the [ACOG
Web site](http://www.acog.org/bookstore/).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on April 14, 1999. The information
was verified by the guideline developer on June 11, 1999. This NGC
summary was updated by ECRI Institute on August 1, 2007. The updated
information was verified by the guideline developer on September 10,
2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008