Uptake of amniocentesis in women aged 38 years or more by the time of the expected date of delivery: a two-year retrospective study

The uptake of amniocentesis for the prenatal diagnosis of chromosome abnormalities in older women (greater than or equal to 38 years by the time of the expected date of delivery) is reviewed over a 2-year period. Overall, 41.3% of women were not tested, including a group of 7% in whom no record of discussion of prenatal diagnosis could be found on review of obstetric records. Refusal of the offer of amniocentesis and late booking were significantly greater in Asian women (P less than 0.01). One-third of chromosomally-abnormal infants were not detected antenatally in the study group.     

Assisted reproductive techniques in women aged 38 years or more

OBJECTIVE: More and more young women are delaying childbearing until the fourth decade of life: thus, Assisted Reproductive Techniques centres receive more and more requests from ageing women. The aim of the study is to analyse the purpose of these requests, the biological and clinical features of these patients and the results in our infertility centre. PATIENTS AND METHODS: A retrospective study was carried out at the CHU of Saint-Etienne from 01.01.01 to 31.12.04. We analysed the social, clinical and biological features of 84 couples when the woman's age was equal or superior to 38 years, representing 218 cycles. A questionnaire was used to collect social data. RESULTS: Several factors can explain the increasing number of ageing women consulting for infertility: extend university time and professional career, professional stability, contraception and late meeting of the partner, false reassuring information concerning progress in ART, second child desire after a late first pregnancy, but also second marital unions and child desire in the redefined couple. In our study, above 40 years old, the pregnancy (19.4 versus 10.5%) and delivery rates (16.7 versus 5.8%) clearly decreased in IUI. Thus, most of the clinicians propose, in first choice, an IVF cycle to a 40 year-old woman. The ultrasound measurement of antral follicle count can accurately evaluate the prognosis in terms of pregnancy (P<0.01) and delivery rate (P=0.03). For patients with unfavourable prognosis, oocyte donation, embryo donation, or adoption can be considered. DISCUSSION AND CONCLUSION: ART cannot compensate for the natural decrease in pregnancy rates and the increase in early miscarriages in ageing women. Therefore, it is essential to inform young women of the negative effects of age on their potential fertility.     

Pregnancy outcome in women aged 40 years or more

Objective: The study aimed to analyze the pregnancy outcome of women aged 40 years or more. Methods: A matched retrospective cohort study comparing women aged 40 years or more with a control group aged 20 to 30 years is described. Multivariate logistic regression models were fitted for the prediction of preterm birth and cesarean delivery. Results: Pregnancy-induced hypertension, preeclampsia and placenta previa were similar in both groups, but a higher rate of gestational diabetes was found in elderly patients (odds ratio [OR] 3.820, 95% confidence interval [CI] = 1.400–10.400; p < 0.0001). Preterm delivery was significantly more frequent in elderly women (OR 1.847, 95% CI = 1.123–3.037; p = 0.020). Gestational diabetes and pregnancy-induced hypertension were strongly associated with preterm delivery and advanced maternal age was not an independent risk factor for preterm delivery. The cesarean delivery rate was significantly higher in the study group (OR 3.234, 95% CI = 2.266–4.617; p < 0.0001). The variables most influencing the cesarean delivery rate were maternal age, analgesia, parity, premature rupture of the membranes and gestational hypertension. No significant differences were detected in neonatal birth weight and Apgar score. Conclusions: Patients aged 40 years or more have been demonstrated to carry a favorable pregnancy and neonatal outcome, similar to younger patients. The risk of cesarean delivery was higher in patients with advanced maternal age, in nulliparous and in women with a previous cesarean section. The risk of preterm delivery was not related to age but it was strongly associated with gestational diabetes and pregnancy-induced hypertension.     

Ovarian stimulation and intrauterine insemination in women aged 40 years or more

Fertility decreases with advancing age. This study retrospectively reviewed the results of ovarian stimulation and intrauterine insemination (IUI) in women 40 years old with diminished ovarian reserve or unexplained infertility who underwent treatment with ovarian stimulation/IUI with clomiphene citrate or gonadotrophin and compared them with the results of IVF and in-vitro maturation (IVM) treatments. The main outcome measures were pregnancy and live-birth rates. The profiles of the patients in ovarian stimulation, IVM and IVF groups were comparable. There were no clinical pregnancies in the clomiphene citrate and IVM groups. The clinical-pregnancy rates in the gonadotrophin and IVF groups were 2.6% and 16.9% and the live-birth rates were 2.6% and 13.7%, respectively. Compared with ovarian stimulation, IVF is most effective for women aged 40 years or more. Attempting success with ovarian stimulation or IVM will delay conception unnecessarily.     

50岁以上妇女妊娠滋养细胞疾病的临床分析

目的探讨50岁以上妇女妊娠滋养细胞疾病的临床特点、治疗及预后。方法回顾性分析北京协和医院自1992年至2002年收治的38例50岁以上妇女妊娠滋养细胞疾病患者的临床资料。结果临床特点患者年龄50～58岁,平均(52±2)岁;主要临床表现为阴道不规则出血。本组38例患者中,葡萄胎5例(13%),侵蚀性葡萄胎(侵葡)19例(50%),绒毛膜癌(绒癌)12例(32%)和胎盘部位滋养细胞肿瘤2例(5%)。初步诊断为葡萄胎的23例患者中,15例行单药预防性化疗,其中10例恶变为侵葡,此10例中3例发生肺转移;8例未行预防性化疗,此类患者均发生恶变(其中侵葡6例、胎盘部位滋养细胞肿瘤2例),且均发生肺转移。上述23例葡萄胎患者中,行单药预防性化疗与否患者的肺转移发生率分别为20%(3/15)、8/8,两者比较,差异有统计学意义(χ2=13.382,P=0.000)。本组38例患者均接受了化疗,其中行子宫切除术者32例,完全缓解率为91%(29/32);未行手术者6例,仅2例完全缓解。结论对于50岁以上出现阴道不规则出血的妇女,必须进行妊娠及妊娠相关疾病的检查。一旦确诊为妊娠滋养细胞疾病,应及早给予化疗,且手术切除子宫是必要的。     

Myomectomy at time of cesarean delivery: a retrospective cohort study

Background  

Myomectomy at time of cesarean delivery is traditionally discouraged because of the risk of hemorrhage. A retrospective cohort study was performed to determine whether myomectomy at time of cesarean delivery leads to an increased incidence of intrapartum and short-term postpartum complications.     

Pelvic organ prolapse surgery in women aged more than 70 years: a literature review

OBJECTIVE: The purpose of the study was to report surgical techniques for pelvic organ prolapse and complications in women aged more than 70 years. PATIENTS AND METHODS: A Medline search was made for articles indexed between 2000 and 2006 and dealing with operative techniques for pelvic organ prolapse. Seven articles in English and French were included. RESULTS: Three hundred and ninety-four women were treated for pelvic organ prolapse. Transvaginal repairs were reported in 97% (384 women). Vaginal function was preserved in 57% (207 women) and vaginal obliteration techniques represented 40% (145 women) of all prolapse surgery. The death rate was 1% (four deaths). The blood transfusion rate was 12%. The mean complication rate was 3.8% with cardiovascular prevalence (seven pulmonary embolisms, two myocardial infarctions, two congestive heart failures, one prolonged angina, two transient arrhythmias, one cerebrovascular accident, one acute renal failure). The temporospatial disorientation rate was 4.6%. DISCUSSION AND CONCLUSION: Vaginal hysterectomy with colpo-perineorrhaphy and sacrospinous ligament fixation are alternative procedures instead of colpocleisis to treat pelvic organ prolapse in women aged more than 70 years. For all pelvic prolapse surgery, the overall perioperative morbidity and mortality rate in elderly women are acceptable. This surgery needs a good collaboration between anesthetist and surgeon team and vigilance during postoperative follow-up.     

Endometrial carcinoma in women aged 40 years or younger: a Japanese experience

We report on the clinical and pathologic findings in 17 cases of endometrial carcinoma in Japanese women aged 40 years or younger. Age of the patients ranged from 16 to 40 years, with a median of 35 years. Nine of 17 tumors (52.9%) were stage I or II (FIGO 1988) but 8 (47.1%) were stage III. Four of the 8 patients with stage III disease had pelvic lymph node metastases and one also had para-aortic lymph node metastasis. One patient had metastasis to the ovary and peritoneal cytology was positive in 4 patients. Histologically, 13 of these 17 patients had endometrioid adenocarcinoma, 3 had adenoacanthoma and 1 had an undifferentiated carcinoma. Ten were well differentiated tumors (G1), 3 were moderately differentiated tumors (G2), and 4 were poorly differentiated tumors (G3). Nine of 17 (52.9%) showed deep myometrial invasion (more than a half of the myometrium) and 5 of 17 (29.4%) demonstrated lymphatic/vascular space invasion. Pelvic and para-aortic lymph node metastases were seen in 4 of 15 (26.7%) and 1 of 15 (6.7%), respectively. Two of these 17 patients died of disease in a relatively short follow-up period. In our experience there is no difference in the survival rates between patients aged 40 years or younger and those over 40 years.     

Cost-effectiveness of human papillomavirus DNA testing for cervical cancer screening in women aged 30 years or more

OBJECTIVE: To evaluate the cost-effectiveness of human papillomavirus (HPV) DNA testing as a primary screening test in combination with cervical cytology in women aged 30 years or more. METHODS: A state-transition mathematical model was used to simulate the natural history of HPV and cervical cancer in a cohort of U.S. women. Strategies included no screening and screening at different frequencies with conventional cytology, liquid-based cytology with HPV testing used for triage of equivocal results, and HPV DNA testing and cytology in combination after women had reached the age of 30. Outcomes measured included cancer incidence, life expectancy, lifetime costs, and incremental cost-effectiveness ratios. RESULTS: The estimated reduction in lifetime risk of cervical cancer varies from 81% to 93% depending on the screening frequency, type of cytology, and test strategy. Every 3-year screening with liquid-based cytology administered to women at all ages and every 3-year screening using HPV DNA testing and cytology in combination administered to women aged 30 years or more provide equivalent or greater benefits than those provided by annual conventional cytology and have incremental cost-effectiveness ratios of US dollars 95300 and US dollars 228700 per year of life gained, respectively. In comparison, annual screening with HPV DNA testing and cytology in combination provides only a few hours of additional life expectancy and has a cost-effectiveness ratio of more than Us dollars 2000000 per year of life gained. CONCLUSIONS: For women aged 30 years and more, every 2- or 3-year screening strategy that uses either HPV DNA testing in combination with cytology for primary screening or cytology with reflex HPV DNA testing for equivocal results will provide a greater reduction in cancer and be less costly than annual conventional cytology.     

Triplet pregnancies in women aged 40 or older: a matched control study

OBJECTIVE: To determine, in triplet pregnancies, if maternal age is associated with adverse outcome in terms of birth weight characteristics. STUDY DESIGN: We analyzed a nationwide cohort of live-born triplets compiled by Matria Healthcare (Marietta, Georgia). We compared all 171 mothers > or = 40 years old with randomly selected and matched-for-parity mothers aged 25-29 and 35-39 years. The main outcome measures were length of gestation and individual and total triplet birth weight. All the subjects had private health insurance. The sample size was adequate to detect 5% differences at a power of 80%. RESULTS: Birth weights for infants A, B and C were significantly higherfor mothers > or = 40 years (P = .016, .01, and .03, respectively); total triplet birth weight was significantly higher as compared with that in the younger controls (P =.01). Gestational ages were similar in the 3 groups. In addition, the frequencies of births at < 28 weeks and of < 1,000 g were reduced by one-third or more in women aged 40 or older as compared to the younger controls (2.3% vs. 6.4% and 4.5% vs. 7.0%, respectively). CONCLUSION: Older mothers of triplets have better outcomes than do their younger counterparts in terms of total triplet birth weight.     

Morbidity of incontinence surgery in women over 70 years old: a retrospective cohort study

OBJECTIVE: To compare the success rate and complications after colposuspension and tension-free vaginal tape (TVT) insertion in women aged 70 years or more compared with younger women. DESIGN: A retrospective study of patients having surgery between November 2000 and October 2002. SETTING: A tertiary referral, academic urogynaecology unit in a University teaching hospital. POPULATION: Two hundred and twenty-six women having surgical treatment for urinary incontinence. METHODS: Data on cure/improvement and complications were extracted from the notes. Patients were grouped by age at surgery and the odds ratios (OR) and 95% confidence intervals (CI) for each outcome were calculated. MAIN OUTCOME MEASURES: Subjective cure rate and the incidence of complications by age group. RESULTS: One hundred and three patients had colposuspension, 11 (10.7%) aged 70 or more. One hundred and twenty-three patients had TVT insertions, 23 (18.7%) aged 70 or more. The cure rate for each procedure was similar between age groups. After colposuspension, urinary tract infection (UTI; OR 11.33; 95% CI 2.61, 49.28) and long term self-catheterisation (percentage of difference 9.1; 95% CI 3.0, 15.2) were more common in women over 70. After TVT, repeat urodynamics (OR 3.91; 95% CI 1.11, 13.76), recurrent UTI (OR 4.22; 95% CI 1.03, 17.26) and tape division (OR 29.12; 95% CI 3.20, 264.86) were more common in older women. CONCLUSIONS: Incontinence surgery carries a higher risk of complications in the elderly including UTI and voiding dysfunction. Extended antibiotic prophylaxis and intermittent self-catheterisation training should be offered to elderly women before surgery.     

Midwife or doctor: a study of pregnant women making delivery decisions

Eighty-eight women from diverse educational backgrounds were interviewed as they made several important and related life decisions during their pregnancies. In this article, the focus is on the choice of birth attendant. There were few differences between those women who did and did not consider a midwife. Women who selected a midwife reported feeling more knowledgeable about birth attendants, more in control over the birth attendant decision, more satisfied about their delivery decisions, more in control of and satisfied with pain medication decisions, more autonomous in their pregnancy decision making, and more in agreement with "alternative birth" philosophies. and less in agreement with "conventional birth" philosophies. The participants also reported receiving more approval from spouse/significant other and friends, were more likely to use "gut instinct" and previous experience or habit to make pregnancy decisions, and were more ready to make these decisions than were women who had not selected a midwife as their primary birth attendant.     

Significant intraventricular hemorrhage is more likely in very preterm infants born by vaginal delivery: a multi-centre retrospective cohort study

Objectives: The objective of this study is to determine the association between mode of delivery (vaginal delivery [VD] versus cesarean section [CS]) and the rate of significant intraventricular hemorrhage (sIVH) in preterm infants.

Methods: A multicenter retrospective cohort study, based on data collected from the Vermont Oxford Network database. Infants born between 23 and 31⁺⁶ weeks of gestational age between 2001 and 2014 were identified. Exposure was the mode of birth (VD versus CS). Primary outcome was development of sIVH. Data were analyzed using univariate and multivariate statistical methods.

Results: A total of 1575 infants were eligible. Nine hundred and two infants were born by CS and 673 by VD. Univariable analysis showed that infants born vaginally were more likely to have sIVH (p?p?p?=?.010) and have a longer hospital stay (p?=?.006). After adjusting for available confounders, multivariable analysis persistently showed that infants between 23 and 27 weeks born by CS were less likely to develop sIVH [OR 1.61 (1.01–2.58), p?=?.049].

Conclusions: sIVH is less common in very preterm infants (23–27 weeks of gestation) delivered by CS. However, neurodevelopmental risks associated with survival at this early age, as well as increased maternal morbidities must also be considered.     

The complication and mode of delivery in Chinese women with severe preeclampsia: a retrospective study

Objective: Severe preeclampsia is a serious threat for pregnant women and fetuses. The complications of severe preeclampsia greatly affect perinatal outcome. This study aimed to investigate the complication and delivery mode of Chinese pregnant women with severe preeclampsia, and analyze the change in these aspects in the past decades. Methods: Clinical data of 1713 pregnant women with severe preeclampsia were collected and analyzed. The patients were divided into two groups: early period (1985–1997) and later period (1998–2010). Results: The complications for severe preeclampsia included preterm birth, fetal distress, postpartum hemorrhage, fetal growth restriction (FGR). Compared to early period, the rates of preterm birth, FGR, oligohydramnios, abnormal pregnancy outcome increased while the rates of fetal distress, postpartum hemorrhage and eclampsia decreased in later period. The rate of cesarean section was 73.073% in the early period and increased to 88.258% in the later period. Accordingly, the rate of natural childbirth, forceps extraction, vacuum extraction and breech extraction decreased in the later period. Conclusions: Our data provide important information on the complication and mode of delivery in Chinese women with severe preeclampsia in the past decades, which may be helpful for clinical management of severe preeclampsia in Chinese women.     

The course of pregnancy and delivery in women after genetic amniocentesis before and after 35 years of age

OBJECTIVES: The demand for genetic amniocentesis in case of young pregnant women has significantly increased due to various new indications. Moreover, nowadays a growing number of women aged > or =35, who required genetic amniocentesis, get pregnant The aim of the following study has been to compare the course of the pregnancy, the delivery and the condition of the newborn in two groups of patients: 18-34 years old and > or =35 years old. MATERIAL AND METHODS: 783 women underwent the procedure of amniocentesis at the Department of Obstetrics of Medical University of Gdansk in 1996-2003. A group of 540 women, who answered the questionnaire about the course of the pregnancy and the delivery after the procedure, has been isolated. RESULTS: Fetal loss occurred in 2 cases (1.6%) in the group of the younger women and in 8 cases (0.8%) in the group of > or =35 year-olds (p=0.84). There was no statistically significant difference between younger and older patients when comparing complications after the procedure in the first three weeks following amniocentesis: spotting, bleeding, leakage of amniotic fluid. Frequency of late complications such as gestational diabetes mellitus, pregnancy induced hypertension and urinary tract infections were comparable in both age groups women. Cesarean section has been more frequently performed in case of the older women than in the group of younger patients, with statistical difference p=0.003. In most cases (33.9%) it has been an elective cesarean section, performed due to advanced maternal age rather than any obstetric cause. Frequency of pneumonia and the number of respiratory infections in the newborns have been comparable in both groups. CONCLUSIONS: Prenatal invasive diagnosis has no influence on frequency of complications during pregnancy and delivery in the group of women less than 35 years old and more than 35 years old.     

50岁以上妇女恶性滋养细胞疾病的诊治

本文回顾性分析了我院20年间50岁以上恶性滋养细胞疾病43例。提出50岁以上妇女发生恶性滋养细胞疾病并非少见,该年龄阶段误诊率高达44％,与对末次妊娠性质缺乏重视有关。并认为葡萄胎在该年龄阶段恶变率高,应作预防性子宫切除术。由于该年龄组化疗副反应出现率高而严重,临床上应引起重视。     

Factors affecting the decision regarding amniocentesis in women at genetic risk because of age 35 years or older

OBJECTIVE: To evaluate the effects of anamnestic factors and sonographic findings on the patient's decision regarding amniocentesis in a cohort of women at genetic risk because of advanced age. METHODS: All women 35 years of age or older registered for prenatal care between January 1990 and December 1998 were asked about their attitude towards genetic amniocentesis during the course of individual genetic counseling and once again after ultrasound examination inclusive of markers of aneuploidies (nuchal fold thickness greater than 6 mm, renal pyelectasis, choroid plexus cysts, and hyperechogenic bowel). Their attitudes towards genetic amniocentesis before and after ultrasound examination were compared using chi-square, Fisher's exact test, Mann-Whitney U-test, and logistic regression analysis, with a two-tailed p < 0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. RESULTS: Among the 1486 women in the cohort, 1368 (97%) expressed an opinion towards genetic testing at the time of counseling: 501 (37%) were in favor and 867 (63%) were against having the procedure. After ultrasonographic examination, 33% (446/1368) of women opted for amniocentesis, 36% (146/402) after abnormal findings and 31% (300/966) after normal ultrasound findings. Significantly more women with abnormal than normal ultrasound findings opted for diagnostic testing in both groups. Overall, only 8% (115/1368) of women changed their attitude towards diagnostic testing after ultrasonographic examination. Normal sonographic findings were three times more likely to change the attitude of women initially interested in amniocentesis than abnormal sonographic findings did in women a priori not interested in the procedure (20% versus 7%, p < 0.001, OR = 3.2, 95% CI 1.8; 5.8). CONCLUSIONS: In a cohort of women at genetic risk because of advanced age, the key determinant of the choice regarding genetic amniocentesis is the a priori opinion of the woman towards the procedure, which was expressed by 93% of women. Ultrasonography plays a secondary role in changing or confirming women's attitude towards invasive diagnostic testing. Normal sonographic findings affect women's decisions more powerfully than abnormal sonographic findings, suggesting that ultrasonography has an important reassuring function for the woman.