Complications of Term Pregnancies Beyond 37

Weeks of Gestation
Aaron B. Caughey, MPP, MPH, and Thomas J. Musci, MD
OBJECTIVE: To estimate when rates of pregnancy complications increase beyond 37 weeks of gestation.
METHODS: We designed a retrospective, cohort study of all
women delivered beyond 37 weeks of gestational age from
1992 to 2002 at a single community hospital. Rates of
perinatal complications by gestational age were analyzed
with both bivariate and multivariable analyses. Statistical
significance was designated by P < .05.
RESULTS: Among the 45,673 women who delivered at 37
completed weeks and beyond, the rates of meconium and
macrosomia increased beyond 38 weeks of gestation (P <
.001), the rates of operative vaginal delivery, chorioamnionitis, and endomyometritis all increased beyond 40 weeks
of gestation (P < .001), and rates of intrauterine fetal death
and cesarean delivery increased beyond 41 weeks of gestation (P < .001).
CONCLUSION: Risks to both mother and infant increase as
pregnancy progresses beyond 40 weeks of gestation.
(Obstet Gynecol 2004;103:57 62. 2004 by The American College of Obstetricians and Gynecologists.)
LEVEL OF EVIDENCE: II-3

It was noted in 1951 that although pregnancies persisting

beyond 300 days occurred less than 5% of the time, they
accounted for 30% of perinatal deaths.1 Thus, since its
advent, one intent of antenatal fetal surveillance has been
the prevention of fetal death among postterm pregnancies. In the 1970s and 1980s, this was commonly defined
as patients beyond 42 completed weeks, or 294 days,2
which complicates more than 10% of pregnancies,3 and
this remains the definition used by the American College
of Obstetricians and Gynecologists (ACOG) today.
However, the use of a 42-week threshold was questioned
by Bochner et al4 in a 1988 study, which showed a
From the Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco; and Department of Obstetrics and Gynecology,
California Pacific Medical Center, San Francisco, California.
Dr. Caughey is supported by the National Institute of Child Health and Human
Development, Grant #HD01262 as a Womens Reproductive Health Research
Scholar.
VOL. 103, NO. 1, JANUARY 2004
2004 by The American College of Obstetricians and Gynecologists.
Published by Lippincott Williams & Wilkins.

decreased rate of stillborn fetuses and fetal distress during labor in a group of patients who began antenatal
testing at 41 weeks, as compared with the control group,
which began testing at 42 weeks of gestational age. This
has led to testing strategies that begin increasingly earlier
for postdates testing. Most recently, the gestational age at
which clinical concern should be raised was questioned
in a study5 that asserted that concerns regarding the
morbidity and mortality of pregnancies at and beyond
term should be weighed against the risks of induction of
labor. Traditionally, there has been concern that induction of labor will lead to an increased rate of cesarean
delivery. However, there are an increasing number of
studies5,6 that suggest this concern might be outweighed
by risks of other pregnancy complications. Furthermore,
the concern regarding the increased rate of cesarean
delivery related to induction might be unfounded when
considering research that finds that cesarean rates are
similar between patients managed with induction versus
expectant management.6,7
Given these changes over the past decades, the question remains: At what gestational age does the benefit of
induction of labor outweigh that of expectant management? In addition to an increased perinatal mortality
rate,4,5,8 10 numerous studies have associated postterm
pregnancies with increased rates of meconium and meconium aspiration syndrome,4,11 oligohydramnios,12 macrosomia,4,13,14 fetal birth injury,15 fetal distress in labor,4,10,16 and cesarean delivery.4,14 Most studies15,17,18
that examine gestational age do so by establishing thresholds, such as 41 or 42 weeks, and comparing rates of
complications beyond this threshold with those in patients delivered below the threshold. However, studies5,19,20 that have examined the risk of fetal death by
week of gestational age show that rates increase in a
steadily rising fashion before 42 weeks of gestation. If
this complication of pregnancy increases not as a discrete
risk beyond some particular gestational age, but instead
continuously with increasing gestational age, other complications associated with postterm pregnancies might do
the same.

0029-7844/04/$30.00
doi:10.1097/01.AOG.0000109216.24211.D4

57

Another theoretic concern with the existing literature

regarding perinatal complications of pregnancy is the
quality of the pregnancy dating. Because we have improved the dating of pregnancy with the use of ultrasound, we are now better able to identify pregnancies
that go beyond 280 days of gestation.21,22 Bennett et al
recently showed that up to 10% of pregnancies will be
redated by a second-trimester ultrasound and more than
20% by a first-trimester scan (Bennett K, Crane J, OShea
P, Lacelle J, Hutchens D, Copel J. Combined first and
second trimester ultrasound screening is effective in reducing postterm labor induction rates: A randomized
controlled trial [abstract]. Am J Obstet Gynecol 2002;
187:S68). Therefore, studies that examined complications of pregnancy in populations whose pregnancies
were dated primarily by history and physical examination alone are likely to suffer from nondifferential misclassification of gestational age.
In this setting of improved pregnancy dating and a
desire to find trends by week of gestation rather than
simple dichotomous comparisons, we sought to explore
complications of pregnancy beyond 37 weeks among an
otherwise low-risk group of patients. Specifically, we
were interested in estimating at what gestational age the
rates of maternal and fetal complications increase over
the prior week of gestation. Further, we were interested
in whether these complications continued to increase
beyond the initial rise and in what fashion.
MATERIALS AND METHODS
We designed a retrospective, cohort study of all women
delivered beyond 37 weeks of gestational age from January 1, 1992, to July 31, 2002, at California Pacific
Medical Center in San Francisco. California Pacific Medical Center is a community hospital that performs more
than 40% of all deliveries in San Francisco and, other
than high-risk transfer patients, nearly all patients who
deliver at California Pacific Medical Center receive prenatal care from a California Pacific Medical Center
affiliated provider. Institutional review board approval
was obtained from the Committee on Human Research
at California Pacific Medical Center. Patients were included in the analysis if they delivered a singleton pregnancy beyond 37 weeks of gestation. Gestational age was
determined in relation to the estimated date of confinement, as defined by 280 days from the last menstrual
period that was either less than 7 days different from a
first-trimester ultrasound or 14 days different from a
second-trimester ultrasound. Otherwise, the estimated
dates of confinement from the earliest ultrasound were
used. The following variables were also exported from
the California Pacific Medical Center perinatal database:

58

Caughey and Musci

Complications of Term Pregnancy

Table 1. Demographics and Descriptive Obstetric Outcomes

Variable
Maternal age 35 y
College graduate
Ethnicity
Black
Asian
Hispanic
White
Other (Asian Indian, mixed race)
Nulliparous
Birth weight 4000 g
Cesarean delivery
Operative vaginal delivery

n (%)
15,281 (33.4)
26,247 (57.3)
1493 (3.3)
17,786 (38.8)
1658 (3.6)
22,753 (49.7)
1983 (4.3)
24,501 (53.5)
4667 (10.2)
8417 (18.4)
7510 (16.4)

maternal age, ethnicity, profession and education, length

of labor, mode of delivery, parity, prior mode of delivery, anesthesia, birth weight, amniotic fluid characteristics, and labor management. The outcome variables
intrauterine fetal death, Apgar scores, admission to the
intensive care nursery, chorioamnionitis, and endomyometritis were also included. Characterization of amniotic
fluid, endomyometritis, and chorioamnionitis were
coded by the attending physicians into the clinical database. Macrosomia was defined as birth weight greater
than or equal to 4500 g. After variables were abstracted
from the database, all patient identifiers were removed
before analysis. This study was approved by the investigational review board at California Pacific Medical
Center.
The data were then compiled and analyzed with
STATA 7 software (Stata Corp., College Station, TX).
Because the primary predictor of interest was gestational
age by week, the dependent variables of interest were
compared in a bivariate fashion with gestational age
from 37 weeks and beyond. For those variables of interest, as well as those that exhibited an increasing bivariate trend before 42 weeks of gestation, a multivariable
logistic regression was performed, including possible
confounders, and with dummy variables for each week
of gestation in the model as independent variables.
Cross-product terms to examine interaction between
predictor variables were created. Their contribution to
the model was tested with the maximum likelihood ratio
test, and they were only kept in the model if they were
statistically significant; this was designated by a P value
less than .05.
RESULTS
During the study period, there were 45,673 women who
delivered beyond 37 completed weeks of gestation.
These patients were predominantly well-educated, as

OBSTETRICS & GYNECOLOGY

Table 2. Fetal Complication Rates by Week of Gestation

Gestational
age wk (n)

Meconium (%)

Intrauterine fetal death*

(per 10,000)

Macrosomia
(per 1000)

Intensive care nursery

admissions (%)

37 (3964)
38 (8865)
39 (13,839)
40 (12,456)
41 (5685)
42 (864)

3
5
8
13
17
18

2.4
3.6
4.0
2.6
9.2
34.7

1.0
5.3
9.5
14.6
30.4
60.2

7.4
4.5
3.9
5.0
5.4
7.2

Statistically significant results are as compared with the rate of complication in the prior week of gestation.
* The rate of intrauterine fetal death is reported per all women pregnant at a particular gestation, the at-risk population for intrauterine fetal death.
All other complications are reported per deliveries at a particular gestation.

P .001 (2 test).

P .05 (2 test).

indicated by the 57% who had completed 4 years of

college (Table 1). When complications of pregnancy
were examined by gestational age, there was a clear
increase in the rates of meconium and macrosomia as
early as 38 weeks of gestation (Table 2). In addition to
the rates of meconium and macrosomia, intensive care
nursery admissions, Apgar scores less than or equal to 6,
operative vaginal delivery, chorioamnionitis, and endomyometritis all increased beyond 40 weeks of gestation (Tables 2 and 3). All of the perinatal outcomes that
increased beyond 40 weeks continued to increase beyond 41 weeks of gestation. At this point, the rates of
intrauterine fetal death and cesarean delivery also began
to increase and continued to rise beyond 42 weeks of
gestation as well.
Gestational age was examined with multivariable logistic regression, controlling for maternal age, ethnicity,
and education, mode of delivery, birth weight, length of
labor, and induction as appropriate in the different models. Beyond 40 weeks, it was found to predict an increased risk for moderate or thick meconium, intensive
care nursery admission, macrosomia, 5-minute Apgar
score less than or equal to 6, chorioamnionitis, and
operative vaginal delivery (Table 4) when compared
with pregnancies delivered before 40 weeks of gestation.

These risks were further increased beyond 41 weeks of

gestation, and intrauterine fetal death, endomyometritis,
and primary cesarean delivery were also found to be
increased among these pregnancies. Interestingly, the
risk for intrauterine fetal death was more than 2.5 times
greater between 41 and 42 weeks of gestation as compared with before 40 weeks of gestation. In this same
comparison, rates of macrosomia and moderate or thick
meconium were tripled and doubled, respectively.
Cross-product terms were not found to be significant in
any of the models and were not used in the final models.
DISCUSSION
We found that there were a number of complications of
pregnancy that rose between 39 and 41 weeks of gestation; that is, before the current threshold of 42 weeks of
gestation, which is used to define postterm pregnancy.
These complications were all examined in multivariable
models, and gestational age beyond 40 and 41 weeks
were predictive of increased risk even when controlling
for known confounders. Most concerning among these
were the rates of intrauterine fetal death and intensive
care nursery admissions. The fact that intensive care
nursery admissions increase is concerning both for neo-

Table 3. Maternal Complication Rates by Week of Gestation

Gestational%
age wk (n)

Operative vaginal
delivery (%)

Primary cesarean
delivery (%)

Chorioamnionitis
(%)

Endomyometritis
(per 1000)

37 (3964)
38 (8865)
39 (13,839)
40 (12,456)
41 (5685)
42 (864)

14.1
14.4
15.5
17.9*
18.5
17.4

14.2
15.1
14.0
15.9*
21.2*
25.0

1.2
1.5
1.7
2.3*
2.7
3.6

8.6
6.4*
7.7
9.6*
15.3*
22.0

Statistically significant results are as compared with the rate of complication in the prior week of gestation.
* P .001 (2 test).

P .05 (2 test).

P .01 (2 test).

VOL. 103, NO. 1, JANUARY 2004

Caughey and Musci

Complications of Term Pregnancy

59

Table 4. Association of Gestational Age With Perinatal Complications in Multivariable Model*

40 wk GA

41 wk GA

42 wk GA

Outcome

OR

(95% CI)

OR

(95% CI)

OR

(95% CI)

Intrauterine fetal death

Moderate or thick meconium
Intensive care nursery admissions
Macrosomia
5-min Apgar score 6
Chorioamnionitis
Endomyometritis
Operative vaginal delivery
Primary cesarean delivery

0.93
1.74
1.12
1.63
1.61
1.21
1.08
1.11
1.13

(0.77, 1.11)
(1.61, 1.89)
(1.01, 1.24)
(1.29, 2.04)
(1.20, 2.16)
(1.07, 1.36)
(0.88, 1.33)
(1.04, 1.23)
(1.03, 1.27)

2.69
2.19
1.12
3.43
2.00
1.21
1.46
1.14
1.32

(1.08, 7.29)
(1.99, 2.41)
(1.02, 1.26)
(2.72, 4.33)
(1.44, 2.78)
(1.04, 1.41)
(1.14, 1.87)
(1.05, 1.23)
(1.17, 1.53)

4.16
2.28
1.53
7.04
2.23
1.66
1.76
1.07
1.46

(1.16, 14.78)
(1.89, 2.75)
(1.12, 1.93)
(5.06, 9.08)
(1.24, 4.00)
(1.24, 2.22)
(1.09, 2.84)
(0.88, 1.23)
(1.12, 1.89)

GA gestational age; OR odds ratio; CI confidence interval.

* Each outcome was examined in a separate multivariable analysis and compared with pregnancies delivered at 39 weeks of gestation, controlling
for maternal demographics, length of labor (except intrauterine and fetal death cesarean delivery), induction (except intrauterine fetal death), and
birth weight (except macrosomia).

natal morbidity and mortality, but also for the use of

medical resources and costs. Further research will need
to investigate long-term neonatal outcomes to see
whether these concerns are well founded.
We also found increases in the rates of meconium and
macrosomia beyond 38 weeks in the bivariate comparison and 40 weeks in the multivariable analysis. These
findings are markers for other neonatal morbidity and
mortality associated with meconium aspiration syndrome23 and birth injury.24 We did not examine the
rates of these more severe outcomes, and even in our
data set with more than 45,000 patients, it is questionable
whether we would have enough power to investigate
such findings. Thus, in our analysis, meconium and
macrosomia served as risk factors for these more serious
neonatal complications.
Pregnancies that are more accurately dated are more
likely to exhibit complications of pregnancy sooner in
population studies. If one were to examine complications
of pregnancy in a cohort of patients who were misdated,
the findings would be biased toward risk increases occurring later in pregnancy. This is described by epidemiologists as nondifferential misclassification, and is based on the
following. Assume that half of the pregnancies are misdated under and half are misdated over the actual gestational age. Thus, the patients who are misdated earlier
than they truly are (ie, their due date is set later than
what it should be, so they are always perceived as being
earlier than their actual gestational age) will have their
complications recorded as occurring earlier in gestation
than actually happened. This will lead to an increase in
the overall number of complications in earlier weeks of
gestation. The patients who are misdated later than they
truly are will actually be at earlier gestational ages than
stated, which will decrease the overall number of complications occurring in later weeks of gestation. Thus, the

60

Caughey and Musci

Complications of Term Pregnancy

difference between later and earlier weeks of gestation

will be narrowed by nondifferential misdating.
The improved dating of pregnancies might reveal a
number of findings in perinatal epidemiology previously
hidden by this nondifferential misclassification that occurs by the use of just the history and physical examination for dating, as compared with ultrasound. As patients pregnancies are better dated, it is important to
elucidate the risks in these pregnancies in a rigorous
fashion. Knowing these risks will improve clinicians
ability to counsel their patients and enable researchers to
explore a variety of predictors and explanations. Finally,
both clinicians and researchers will be able to investigate
the use of interventions to decrease these risks. Currently, antenatal fetal surveillance is used to help identify
those postterm patients at an even higher risk of perinatal
complications. With further evidence consistent with
what we have found in this study, it might be reasonable
to consider such screening at an earlier gestational age.
If antenatal testing is begun at an earlier gestational
age, it is reasonable to assume that more patients with
need for delivery will be identified. The efficacy and risk
profile of the existing and new methods for labor induction will continue to change over time. Thus, we will
need to reassess the risks and the benefits from expectant
management versus labor induction in these patients
with only the most current data. If labor induction
methods improve and the risks of increasing gestational
age begin earlier than previously suspected, there might
be an indication to intervene at an earlier gestational age.
Given our data, it might be found that the balance of
risks and benefits for intervention in low-risk pregnancies should be earlier than current management. The
most recent recommendations by ACOG have defined
that threshold to be at 42 weeks of gestation. However,

OBSTETRICS & GYNECOLOGY

based on these data, we would suggest that this threshold

should at least be reconsidered.
Our study is not without limitations. Despite the high
quality of the data used, we were unable to examine
other complications of pregnancy, such as placental abruption and oligohydramnios because of either underreporting or an interruption in the data-entry process. A
retrospective study can be complicated by missing data
and inaccurate data. However, because this database
was prospectively designed to examine complications
of pregnancy, this concern is likely unfounded. Of the
variables we used, less than 1% were missing data. We
might also be missing other confounding variables.
For example, we did not have information on family
income. However, we felt that socioeconomic status
was well accounted for with the use of education as a
proxy.
Another possible limitation is regarding the generalizability of our study population to that of all pregnant
women. The patients served by this community hospital
are predominantly upper middle class, carry health insurance, and seek prenatal care in the first trimester.
Thus, we sought to examine complications of pregnancy
at term among these patients who are likely to have
excellent pregnancy dating and might be considered to
have lower rates of pregnancy complications for socioeconomic reasons. If anything, that the findings were
significant among these patients suggests that they might
only be more so in other, higher-risk groups. Furthermore, our findings were robust, controlling for maternal
age, ethnicity, and education.
Examining the association between gestational age
and pregnancy complications is important for estimating
both when pregnancies should be screened for complications with antenatal fetal testing, as well as when a
delivery plan should be initiated. These risks of increasing gestational age of pregnancy need to be compared
with the risks of induction to determine the optimal
gestational age for induction of labor. This study examining these risks among a relatively low-risk population
is a first approximation of the maternal and fetal risks in
pregnancies at term. These findings suggest that antenatal fetal testing should begin sooner than current recommendations of 42 weeks of gestation and that the optimal
gestational age to initiate delivery requires further investigation.

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Reprints are not available. Address correspondence to: Aaron
B. Caughey, MD, MPP, MPH, University of California, San
Francisco, Department of Obstetrics and Gynecology, 505
Parnassus Avenue, Box 0856, San Francisco, CA 94143; email: abcmd@uclink.berkeley.edu.
Received May 21, 2003. Received in revised form August 22, 2003.
Accepted September 4, 2003.

OBSTETRICS & GYNECOLOGY