Advanced Maternal Age and the Risk of Cesarean Birth: A Systematic Review

Abstract: Background: The increasing pregnancy rate at advanced maternal age is contemporaneous with the increasing rate of cesarean birth. Several studies have found that advanced maternal age is a risk factor for cesarean birth. The objective of this systematic review was to assess the relationship between advanced maternal age and cesarean birth among nulliparous and multiparous women. Methods: To identify relevant studies, we searched the literature for articles published from January 1, 1995 to March 1, 2008, using Medline, EMBASE, PsychINFO, and CINAHL. We also hand‐searched the bibliographies of retrieved articles to identify additional related studies. We included all cohort studies and all case‐control studies that examined this association in developed countries. The Cochrane Collaboration’s Review Manager software (5.0) was used to summarize the data. Results: Twenty‐one studies met the inclusion criteria and were included in the review. All studies demonstrated an increased risk of cesarean birth among women at advanced maternal age compared with younger women, for both nulliparas and multiparas (relative risk varied from 1.39 to 2.76). Because we found extreme heterogeneity (both statistical and clinical) among the included studies, we did not provide a pooled estimate of the risk of cesarean birth. Conclusions: All included studies illustrated an increased risk of cesarean birth among older women. Fifteen studies adjusted this association for potential confounders, which suggests that a valid and independent association is likely to exist between advanced maternal age and cesarean birth. However, the associated factors for this increased risk are not totally understood in the literature. (BIRTH 37:3 September 2010)     

The Effect of Very Advanced Maternal Age on Maternal and Neonatal Outcomes: A Systematic Review

Objective

To summarize information on the maternal and perinatal outcomes among pregnant women with a maternal age greater or equal to 45 years old compared with women with a maternal age of less than 45.

Predictors of Perception of Pregnancy Risk among Nulliparous Women

ObjectiveTo determine factors associated with perception of pregnancy risk using a conceptual framework based on a review of the relevant literature and the psychometric model of risk perception.DesignA correlational study.SettingAmbulatory care and antepartum units of two tertiary hospitals and selected obstetricians’ offices and prenatal classes in Winnipeg, Canada.ParticipantsA convenience sample of nulliparous women in their third trimester with a singleton pregnancy.MethodsBetween December 2009 and January 2011, the following questionnaires were completed by 159 nulliparous women: the Perception of Pregnancy Risk Questionnaire, the Pregnancy-related Anxiety scale, Knowledge of Maternal Age-related Risks of Childbearing Questionnaire, the SF-12v2 Health Status Survey, the Multidimensional Health Locus of Control, and the Prenatal Scoring Form. Pearson's r correlations and stepwise multivariable linear regression analyses were conducted to achieve the research objectives.ResultsOf the eight proposed factors in the conceptual framework, five factors were significant predictors of perception of pregnancy risk, including pregnancy-related anxiety, maternal age, medical risk, perceived internal control, and gestational age, accounting for 47% to 49% of the variance in risk perception. An interaction between the pregnancy-related anxiety score and maternal age was found.ConclusionsThese results contribute to the literature on perception of pregnancy risk by identifying a new predictor (gestational age), supporting the role of previously known factors in the state of pregnancy, and proposing pregnancy-related anxiety as a pregnancy dread factor in risk perception theories. This knowledge may have implications for developing more effective risk communication models.     

Reproductive Outcome After Sterilization Reversal in Women of Advanced Reproductive Age

Objective: Our objective was to assess the clinical outcome of tubal reversal in women of advanced reproductive age. Methods: A multicenter retrospective chart review of 153 patients who underwent a tubal ligation reversal was carried out. Patients were evaluated according to age. All patients had documented ovulation and a partner with a normal semen analysis by WHO criteria. Outcome measures included rates of clinical pregnancy, ectopic pregnancy, spontaneous abortion, and live birth, and the time to conception. Results: Clinical pregnancy rates were significantly lower in women 40 compared to younger groups. The time to conception was significantly shorter for women <30 compared to women 35. No pregnancies occurred in women 42. Conclusions: Our data support the judicious use of sterilization reversal for infertile women with no male factor through their early forties. Women 42 years should be especially counseled as to the very low success rates.     

Maternal Age,Paternal Age and New-Onset Hypertension in Late Pregnancy

Objective: To examine the association between maternal age, paternal age, and new-onset hypertension in late pregnancy. Methods: We carried out a retrospective cohort study of 9,302,675 pregnant women with live births in the United States between 1995 and 1998. Maternal and paternal ages were analyzed together using “couple age” in multivariate logistic regression models to reduce colinearity between maternal age and paternal age. The effect of paternal age was also analyzed with stratification of maternal age. Results: Compared with couples with both a maternal and paternal age of 20 to 34 years, an older maternal age (above 35 years) was associated with an increased risk for new-onset hypertension, except for couples with a very young father (below 20 years). Younger maternal age (below 20 years) was associated with a decreased risk for new-onset hypertension, except for couples with a very old father (above 45 years). There was no significant association between paternal age and new-onset hypertension with stratification of maternal age. Conclusion: Increased risk for new-onset hypertension in late pregnancy is significantly associated with advancing maternal age, whereas there is no association between paternal age and new-onset hypertension in late pregnancy.     

Comparison of Demographic and Obstetric Characteristics of Canadian Primiparous Women of Advanced Maternal Age and Younger Age

ObjectiveThe rate of pregnancy at advanced maternal age (AMA) has increased during recent decades. The purpose of this study is to compare demographic and obstetric characteristics of Canadian primiparous women of AMA with those aged 20 to 29 years.MethodsWe conducted a secondary analysis of data collected through the national Maternity Experiences Survey (MES) of the Canadian Perinatal Surveillance System. The sample included 301 primiparous women aged 35 years or over and 1564 primiparous women aged 20 to 29 years. Estimates of prevalence for each group and their odds ratios were calculated using sample weights of the survey, and variances were calculated using bootstrapping methods adjusting for sampling design and weights.ResultsWomen of AMA were significantly more likely to be better educated, to have higher income, to be employed, and to continue to work until the end of pregnancy than younger women. They also reported having significantly more information on pregnancy, labour, and birth, and they were more likely to attend prenatal classes. They were more likely to have had a miscarriage or infertility treatment, to request or be offered a Caesarean section, and to have a higher rate of Caesarean section. There were no significant differences in rates of preterm birth, low birth weight, and small-for-gestational age infants.ConclusionPregnant women of AMA differ from younger women in demographic characteristics, knowledge level, and some health behaviours and pregnancy outcomes. The growing number of pregnancies at AMA indicates the need for developing appropriate care plans to address the specific needs of this group.     

高龄孕产妇慢性代谢性疾病的长期管理

目前高龄孕产妇的比例逐渐增加。随着年龄的增长,糖尿病、高血压、高脂血症、肥胖等代谢性疾病患病风险增加,而年龄往往是这些疾病的独立危险因素。因此,高龄孕产妇较年轻者将面临更大的风险,对高龄孕产妇的管理要求也更高。但目前对于高龄孕产妇代谢性疾病的关注点主要在于孕期,对于产后的管理与远期康复的关注度较为缺乏,孕期保健及治疗上仍存在不足及局限。为使孕产妇健康生活质量得到保障,现对高龄孕产妇产后常见慢性代谢性疾病的管理进行综述,增强产科医生对年龄因素的关注与重视。建议采用全局随访理念,加强对高龄孕产妇产后的规范管理,注意定期监测血糖、血脂、血压、体质量和腰围等,从而降低远期代谢性疾病的发病风险。     

Maternal Perception of Preterm Labor

The objective of this study was to determine the reliability of maternal perception of uterine contractions and the influence of gestational age and maternal training on the perception level. Three hundred fifty patients at high risk for preterm delivery were followed from 20 to 35 weeks of gestation. The average maternal perception (79%) of contractions did not significantly vary as a function of gestational age. Four groups of women were identified according to the perception index (PI) defined as the ratio of contractions felt by the mother and the contractions documented by tocodynamometer. Within each group, the PI did not significantly vary during consecutive monitoring sessions, as the women become more familiar with self detection of uterine contractions (R <. 65, P >. 95). Twenty-one percent (±5%) of all preterm uterine contractions were not perceived by the pregnant women from 21 to 35 weeks. Thirty-two patients (9.1%) fail to perceive most or all uterine contractions while 189 (54%) detect most or all at any time during the study period.     

Advanced maternal age

The average age of women at childbirth in industrialised nations has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (>40 years) should be given low dose aspirin (in the presence of an additional risk factor for pre-eclampsia) and offered serial ultrasounds for fetal growth and wellbeing; given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with the woman.     

Older Maternal Age and Intervention in Labor: A Population‐Based Study Comparing Older and Younger First‐Time Mothers in Victoria,Australia

Background: In Australia, birth rates for women aged 35 years or more are significant and increasing and a considerable percentage are first births. This study investigated the effect of maternal age on interventions in labor and birth for primiparous women aged 35 to 44 years compared with primiparous women aged 25 to 29 years. Methods: All primiparous women who gave birth in Victoria, Australia, in 2005 and 2006 (n = 57,426) were included in this population‐based cross‐sectional study. Women were stratified by admission status (private/public). Main outcome measures were induction of labor, augmentation of labor, use of epidural analgesia, and method of birth. Multivariate logistic regression was used to explore the relationship between maternal age and cesarean adjusted for confounders. Results: Older women were more likely to give birth by cesarean section whether admitted as public or private patients. For private patients, total cesarean rates were 31.8 percent (25–29 yr), 46.0 percent (35–39 yr), and 60.0 percent (40–44 yr; p < 0.001) compared with 27.5, 41.6, and 53.4 percent for public patients (p < 0.001). Older women who experienced labor were more likely to have an instrumental vaginal birth or an emergency cesarean section than younger women. Both were more common in women admitted as private patients. Age‐related trends were also seen for induction of labor and use of epidural analgesia. Rates were higher for private patients. Rates of induction were (37.8, 40.2, and 42.5%) for private patients compared with (32.1, 36.7, and 40.1%) for public patients and rates for epidural were (45.3, 49.9, and 48.1%) among private patients compared with (33.3, 38.8, and 39.3%) among public patients. Conclusions: Interventions in labor and birth increased with maternal age, and this effect was seen particularly for cesarean section among women admitted privately. These findings were not fully explained by the complications we considered. (BIRTH 38:1 March 2011)     

The Maternal Age Cut-Off for an Increase in Composite Adverse Outcomes

ObjectiveTo investigate whether there is a specific maternal age cut-off at which there is an increase in maternal and neonatal adverse outcomes.MethodsA retrospective study comparing maternal and neonatal outcomes between nulliparous women of different ages. The receiver operating characteristic model with the Youden index was used to find the best age cut-off using cesarean delivery (CD) and composite adverse outcomes. A multivariable logistic regression analysis was calculated after adjusting for smoking, induction of labour, epidural use, hypertensive disorders, gestational diabetes, and birth weight.ResultsThe study included 11 343 nulliparous women. Age 28 years was found to be the cut-off age at which we found a significant increase in adverse outcomes. Women older than age 28 years had a higher risk of CD than women younger than 28 years (35.7% vs. 21.3%, P < 0.0001). They were also more likely to deliver prematurely (11.9% vs. 7.9%; P < 0.0001) and had higher rates hypertensive disorders (2.3% vs. 1.1%; P < 0.0001) and gestational diabetes mellitus (0.4% vs. 0.1%; P = 0.001). Furthermore, their babies were more likely to be growth restricted (1.1% vs. 0.3%; P < 0.0001). There were no differences in the rates of induction of labour or macrosomia. After adjusting for confounders, we found that women older than 28 years had higher risks of CD and adverse outcomes than younger women (aOR 1.9 [95% CI 1.744–2.1] and aOR 1.6 [95% CI 1.6–1.77], respectively).ConclusionIncreasing maternal age is independently associated with adverse maternal and neonatal outcomes with an age cut-off of 28 years. Women older than age 28 years are at higher risk for composite adverse outcomes than younger women.     

Relative Importance of Maternal Constitutional Factors and Glucose Intolerance of Pregnancy in the Development of Newborn Macrosomia

The purpose of this case-control study was to determine the relative importance of various predictors of newborn macrosomia, with particular reference to maternal constitutional factors and glucose intolerance of pregnancy. Macrosomia was defined by both absolute birthweight ±4,000 g and birthweight ±90th centile for gestational age. One thousand mother/newborn pairs [209 macrosomic (cases) and 791 non-macrosomic newborns (controls)] were recruited. Mothers with pre-gestational diabetes mellitus were excluded. Data on prepregnancy and pregnancy variables were collected by review of prenatal, labour, and delivery and newborn assessment records and interview with the mother.

Predictors that entered the stepwise multiple regression model in order of significance were: previous history of macrosomia, increasing maternal weight, nonsmoking status, multiparity, male newborn gender, gestational age of 40–42 weeks, North American Aboriginal ethnicity, maternal birthweight >4,000 g, maternal height and maternal age >17 years. Glucose screen positive/100-g oral glucose tolerance test (GTT) negative status was a significant predictor for macrosomia as defined by birthweight greater than the 90th percentile for gestational age, but not for absolute birthweight over 4,000 g. It was the least significant of all the factors examined. Treated gestational diabetes was not a significant predictor.

By multivariate analysis, maternal constitutional factors are more powerful predictors of newborn macrosomia than maternal mild glucose intolerance. Treatment of mothers with GDM may be masking the effect of more pronounced carbohydrate intolerance.     

孕妇年龄与妊娠高危因素及妊娠结局的关系

目的:探讨孕妇年龄与妊娠高危因素、妊娠结局的关系。方法:通过对2015年1月1日至2016年10月31日期间,在南方医科大学珠江医院分娩的所有产妇作为研究分析对象,按年龄划分为4组,≤24岁组543例(13.76%)、25~29岁组1648例(41.18%)、30~34岁组1208例(30.61%)、≥35岁组547例(13.86%)。统计4组不同年龄孕妇妊娠合并症、并发症的发生率和妊娠结局,将25~29岁组设为对照组(OR=1),进行二元Logsitic回归分析年龄与妊娠合并症、并发症及妊娠结局等的相关性。结果:在年龄30岁孕妇中,不良孕产史、本次辅助生殖助孕妊娠、妊娠合并子宫肌瘤、妊娠期糖尿病、瘢痕子宫OR值均1,且随年龄组增加,OR值递增。前置胎盘、多胎妊娠、产后出血,分娩巨大儿、低体质量儿、早产儿,在年龄≥35岁组中OR值1。子痫前期中年龄≤24岁组、≥35岁组OR值均1。在30~34岁组出生缺陷儿的OR值1。结论:对不同年龄孕妇,要有针对性地采取围生期检查及保健工作,及时对高危孕妇进行干预,积极治疗相关合并症,预防并发症,适时选择最佳分娩方式,综合保障母婴健康。     

Pregnancy outcomes in women of very advanced maternal age

OBJECTIVE: To assess outcomes for pregnancies progressing beyond 20 weeks' gestation in women of very advanced maternal age. DESIGN: Retrospective cohort study. SETTING: Two tertiary level obstetric hospitals. POPULATION: Women aged 45 years or more at the time of delivery over a 10-year period from 1 January 1992 to 31 December 2001. METHODS: Information regarding maternal, pregnancy and neonatal outcomes was obtained from the medical records. For comparison, routinely collected data from the obstetric database was obtained for women aged 20-29 years. RESULTS: Seventy-seven pregnancies in 76 women aged 45 years and over were registered in the 10-year period. There were 74 liveborn singletons, two sets of liveborn twins and one set of twins stillborn at 20 weeks' gestation. Sixteen women were primiparous. Eighty-four percent of pregnancies were conceived naturally and 53% underwent prenatal chromosomal determination; 53% of women had no pre-existing medical problems, 13% had hypertensive disorders of pregnancy and 8% of women developed gestational diabetes. There were 10 preterm and six post dates deliveries. The Caesarean section rate was 49%, compared to 23% in the 20-29 years age group (P < 0.001). Ten percent of neonates were small for gestational age, and 8% were large for gestational age. Seventeen percent required admission to the special care nursery and 6% had congenital abnormalities. CONCLUSIONS: Maternal and neonatal outcomes in this series were generally good. There was a significantly increased rate of Caesarean section. Overall, this study is reassuring for women aged 45 and over who have good general health and a chromosomally normal fetus.     

Maternal anxiety and fetal movement patterns in late pregnancy

Objective: To determine whether maternal anxiety affects fetal movement patterns in the third trimester of pregnancy.

Methods: The inclusion criteria were a state of good health and a singleton pregnancy between 36 and 40 weeks. Thirty healthy pregnant women were included. The Beck Anxiety Inventory (BA) questionnaire with 21 self-reported items validated for the Brazilian population was applied. The women were asked to record the number of minutes taken to perceive 10 fetal movements once a day for one week. Anxiety symptoms were rated as moderate or severe according to the BAI total score.

Results: The mean BAI score was 20.8 (SD?=?10.2) and the mean time to count 10 fetal movements was 24.3?min (SD?=?6.6?min). The BAI items significantly associated with moderate or severe maternal anxiety were numbness or tingling, fear of the worst happening, terrified, feeling of choking, fear of losing control and fear of dying. There was a statistically significant negative correlation between the total BAI score and the mean time of 10 perceived fetal movements (p?<?0.0001; rho?=??0.70; 95% CI for rho ?0.84 to ?0.45).

Conclusions: Maternal anxiety seems to affect fetal movement patterns in late pregnancy and is associated with the mother’s increased perception of fetal activity.     

Risk Factors of Maternal Death in Mexico

ABSTRACT: Background: One of the United Nations’ Millennium Development Goals for 2015 is to reduce the maternal mortality ratio by three fourths. Ninety‐nine percent of maternal deaths occur in developing countries, and the World Health Organization encourages investigations in these settings to determine the risk factors of maternal deaths. Our aim was to identify these risk factors in a hospital‐based study in Mexico. Methods: The study was conducted at the Hospital of Obstetrics and Gynecology at the Mexican Institute of Social Security in Leon, Guanajuato, Mexico, from January 1, 1992, to March 31, 2004. Women were divided into groups of 110 individuals who had died during pregnancy, delivery, or postpartum, and 440 women who survived the postpartum period. We used a logistic regression analysis to find the significant risk factors for maternal deaths. Odds ratios with 95% t confidence intervals were estimated. Results: The maternal mortality ratio was 47.3 per 100,000 live births. The main causes of death were hemorrhage (30.9%), preeclampsia/eclampsia (28.2%), and septic shock (10.9%). Six factors were significantly associated with maternal death: age (OR = 1.09, 95% CI = 1.00–1.18), marital status (OR = 16.2, 95% CI = 1.3–196.1), number of antenatal visits (OR = 1.3, 95% CI = 1.0–1.6), preexisting medical conditions (OR = 23.3, 95% CI = 6.6–81.6), obstetric complications in previous pregnancies (OR = 28.3, 95% CI = 4.9–163.0), and mode of delivery (OR = 1.6, 95% CI = 1.0–2.4). Conclusions: Socioeconomic, medical, and obstetric risk factors are associated with maternal deaths in Mexico. (BIRTH 34:1 March 2007)     

Outcomes of multiple gestations with advanced maternal age

Objective.?To investigate outcomes of twin gestations with advanced maternal age (AMA).

Study design.?Historical cohort of twin gestations cared for by a maternal–fetal medicine faculty practice. Outcomes of patients with AMA (70) and non-AMA (75) were compared. AMA was defined as age ≥35. Analysis including mode of delivery, gestational age at delivery and overall complications was performed. Significance was determined using the chi-square test or the Student's t-test.

Results.?The Cesarean rate for AMA was significantly greater compared to non-AMA (80.0% vs. 54.7%; p = 0.001). The main reason for the increased rate was uterine dysfunction. The mean gestational age at delivery for AMA was significantly greater than for non-AMA (36.7 weeks vs. 35.4 weeks; p = 0.02). There were no differences in rates of other adverse outcomes including gestational hypertension, pre-eclampsia, gestational diabetes, suspected fetal growth restriction, preterm birth, low birth weight or low birth weight percentiles. This remained true when we compared the 32 women ages ≥40 years to 118 women ages <40 years.

Conclusion.?Among twin pregnancies, AMA women are not at an increased risk of adverse pregnancy outcomes, aside from an increased rate of cesarean delivery.