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# Management of Prolonged Pregnancy

*Evidence Reports/Technology Assessments, No. 53*

Evan R Myers, MD, MPH, Richard Blumrick, MD, Andrea L Christian, BA, Santanu Datta, MBA, MS, Rebecca N Gray, DPhil, Jane T Kolimaga, MA, Elizabeth Livingston, MD, Andrea Lukes, MD, MHSc, David B Matchar, MD, and Douglas C McCrory, MD, MHSc.

Agency for Healthcare Research and Quality (US)2002 May

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## Structured Abstract

#### Objective:

            Approximately 18 percent of pregnancies in the United States extend beyond 41 weeks gestation, 7 percent beyond 42 weeks. Risks of adverse perinatal and maternal outcomes increase with increasing gestational age beyond term. This report assesses the literature on the benefits, risks, and costs of different strategies for managing prolonged pregnancy in order to avoid adverse perinatal and maternal outcomes.

#### Search Strategy:

            Published literature on the management of prolonged pregnancy was identified in MEDLINE, CINAHL, EMBASE, HealthSTAR, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness for the years 1980 through 2001. MeSH terms included "pregnancy, prolonged" and "post$ pregnan$.tw". 

#### Selection Criteria:

            Study designs considered included randomized controlled trials, cohort studies, and large (n > 20) case series with or without controls. Studies were included if the study population included women with prolonged pregnancy and data were provided that were relevant to one or more of the key research questions. Studies were excluded from formal abstraction if they did not report on original research, the patient population did not include women with prolonged pregnancy, the study design was a single case report or small case series, or a 2-by-2 table could not be constructed (for studies of test characteristics).

#### Data Collection and Analysis:

            Paired reviewers independently screened each abstract and article and performed the data abstraction. Included studies were graded for internal and external validity. Supplemental data were collected from the Nationwide Inpatient Sample.

#### Main Results:

            Although there is no direct evidence that antepartum testing reduces perinatal mortality in prolonged gestation, retrospective data suggest that morbidity may be reduced. Selection of appropriate outcomes for evaluating antepartum testing is difficult since mortality and morbidity are rare, and commonly used surrogate markers have substantial weaknesses. All currently used tests and combinations of tests have better specificity than sensitivity but good negative predictive values. There are no definitive data supporting the superiority of any particular testing method.

Most studies of interventions for the induction of labor do not report results specifically for women induced because of prolonged pregnancy or its complications. In general, agents that result in more efficient induction of labor also have higher rates of fetal heart rate pattern changes associated with frequent uterine contractions.

Pooled analysis of randomized trials of planned induction versus expectant management with antepartum testing suggests that planned induction reduces the risk of perinatal death with no increase in other perinatal or maternal morbidity, including cesarean section. At least 500 inductions are needed to prevent one perinatal death.

There are virtually no data on patient values and preferences for management options. There also are no published data on potential differences in epidemiology or outcomes of prolonged pregnancy in racial, ethnic, or socioeconomic subgroups and no data allowing comparison of the cost-effectiveness of different strategies for managing prolonged pregnancy.

#### Conclusions:

           Induction of labor at 41 weeks or beyond results in fewer perinatal deaths compared with antepartum testing, but at least 500 inductions are necessary to prevent one death. There is insufficient evidence to recommend any specific induction agent in this setting. Additional high-quality research is needed.

## Contents

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                        - Preface
                        - Summary
                        - 1. Introduction                           - Background
                          - Normal Variation versus Pathology
                          - Errors in Dating
                          - Burden of Illness: Risks Associated with Prolonged Pregnancy
                          - Scope and Purpose
                          - Patient Populations
                          - Practice Settings
                          - Target Audiences
                        - 2. Methodology                           - Topic Assessment and Refinement
                          - Literature Search and Selection
                          - Data Abstraction
                          - Quality Scoring
                          - Quality Control Procedures
                          - Supplemental Data Sources
                          - Supplemental Analyses
                        - 3. Results                           - Approach
                          - Results
                          - Methodological Issues
                          - Summary
                          - Approach
                          - Results
                          - Methodological Issues
                          - Summary
                          - Approach
                          - Results
                          - Methodological Issues
                          - Summary
                          - Approach
                          - Results
                          - Methodological Issues
                          - Summary
                        - 4. Conclusions                           - Summary of Findings
                          - Research Implications
                          - Limitations of the Current Literature
                          - Limitations of the Report
                          - Suggested Strategies for Using this Report
                        - 5. Future Research                           - Estimation of Risks Associated with Prolonged Gestation
                          - Testing Methods
                          - Planned Induction versus Expectant Management
                          - Interventions for Induction
                          - Special Populations
                        - List of Abbreviations and Acronyms Used in the Report and Evidence Tables
                        - Evidence Tables
                        - Appendixes
                        - References
                        - Bibliography

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Prepared for: Agency for Healthcare Research and                            Quality, U.S. Department of Health and Human Services.1             Contract No. 290-97-0014. Prepared by: Duke Evidence-based Practice Center, Durham, NC.

#### Suggested citation:

Myers ER, Blumrick R, Christian AL, et al. Management of prolonged pregnancy. Evidence                Report/Technology Assessment No. 53 (Prepared by Duke Evidence-based Practice Center,                Durham, NC, under Contract No. 290-97-0014). AHRQ Publication No. 02-E018. Rockville,                MD: Agency for Healthcare Research and Quality. May 2002.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care, and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

The authors of this report are responsible for its content. Statements                        in the report should not be construed as endorsement by the Agency for                        Healthcare Research and Quality or the U.S. Department of Health and                        Human Services of a particular drug, device, test, treatment, or other                        clinical service.

                        - 1
                        - 
2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK36890

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                    - Cite this Page Myers ER, Blumrick R, Christian AL, et al. Management of Prolonged Pregnancy. Rockville (MD): Agency for Healthcare Research and Quality (US); 2002 May. (Evidence Reports/Technology Assessments, No. 53.)

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