Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal testing be initiated?

We sought to determine if advanced maternal age (AMA) is a risk factor for intrauterine fetal demise (IUFD). We used a U.S. Centers for Disease Control and Prevention database and analyzed outcomes in women 15 to 44 years of age with term singleton gestations. Cox proportional hazards models and Cochran-Mantel-Haenszel tests were used. Results were controlled for maternal race and smoking. After excluding congenital anomalies and medical complications, 6,239,399 singleton term deliveries were identified. When compared with women 25 to 29 years of age, the risk of IUFD increased with advancing age: 30 to 34 years, odds ratio [OR] = 1.24 (95% confidence interval [CI], 1.13 to 1.36); 35 to 39 years, OR = 1.45 (95% CI, 1.21 to 1.74), and 40 to 44 years, OR = 3.04 (95% CI, 1.58 to 5.86). The risk of IUFD for women 40 to 44 years of age at 39 weeks is comparable with that of 42 weeks in those 25 to 29 years of age. We concluded that AMA is an independent predictor of IUFD, and a strategy of antenatal testing in those > or = 40 years of age beginning at 38 weeks may be considered.     

Is routine amniocentesis for advanced maternal age still indicated?

OBJECTIVE: To evaluate a policy of selective rather than routine use of amniocentesis for advanced maternal age. METHOD: A consecutive series of 359 pregnant women aged 38-47 underwent nuchal translucency measurement (NTM) at 10-14 weeks, maternal serum screening (MSS) by alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG) at 15-17 weeks, and second trimester ultrasound at 21-23 weeks. Women with NTM <3 mm, MSS-derived risk <1/250, and a normal second trimester sonography were considered at low risk and were suggested not to have an amniocentesis. RESULTS: Either the NTM or MSS test was positive in 130 women; 105 (81%) of them elected to have an amniocentesis, versus 122 (53%) of 229 in whom both tests were negative (p < 0.001). Nineteen (5%) of 359 patients had NTM > or =3 mm; all 7 cases of Down's syndrome were in this group; 122 (34%) of 359 patients had a MSS-derived risk > or =1/250; 6 of the 7 cases of Down's syndrome were in this group: Ten patients had an abnormal second trimester ultrasound, 1 of which had trisomy 18. Of the 219 patients with MSS-derived risk <1/250, a NTM <3 mm, and a normal second trimester ultrasound, none had a baby with a chromosomal abnormality (95% confidence interval: 0-1.4%). CONCLUSION: Amniocentesis may be offered on a selective rather than routine basis in women over 38, based upon the results of noninvasive screening tests.     

Is primiparity a risk factor for advanced maternal age pregnancies?

Objective: Currently, more women are delaying childbearing until their 40s.This study compared the pregnancy and maternal features, pregnancy and foetal outcomes between multiparous and primiparous patients. We compared the same factors between assisted reproductive technology (ART) and non-ART primiparous patients because of the high proportion of ART used in the primiparous patients.

Methods: The study retrospectively examined 1680 patients, 35 years of age and older, between March 2008 and February 2015.

Results: Comparing the features of these two groups, there was an increased incidence of employment and the use of ART in primiparous patients, while birthweight tended to be higher in the multiparous group. There were no significant differences in pregnancy complications other than hypertension disorders, such as pre-eclampsia and HELLP syndrome, which were significantly more frequent in primiparous patients. The rates of foetal growth retardation and perinatal death were significantly higher in primiparous women. Comparison of the data between ART and non-ART primiparous patients indicated that the ART group had a higher initial body mass index and a lower smoking rate. No significant differences in pregnancy complications or foetal outcome were observed between these two groups.

Conclusion: Primiparity is associated with increased pregnancy and foetal complications in advanced age pregnancies. However, the use of ART in this age group does not seem to be an additional risk factor.     

First-time mothers’ experiences of preparing for childbirth at advanced maternal age

ObjectiveTo explore the lived experiences of preparing for childbirth for nulliparous women aged 35–44 and determine how mature first-time mothers’ can be better supported regarding childbirth preparation.DesignThe research study comprised a cross-sectional qualitative design utilising Interpretative Phenomenological Analysis to provide a deep exploration into the experience of mature age women.SettingParticipants resided in South Australia and Victoria, Australia, in regional, suburban and inner-city locations.ParticipantsFourteen nulliparous women aged 35–44 were recruited in their third trimester of pregnancy using purposeful sampling.MethodData were collected by conducting in-depth semi-structured interviews during 28–36 weeks of pregnancy. Data were transcribed and analysed using Interpretative Phenomenological Analysis to identify themes of mature first-time mothers’ preparations for childbirth.FindingsThe super ordinate theme “Building confidence for childbirth” describes mature first-time mothers’ experience of preparing for childbirth. This process appears to influence women's information seeking behaviour, expectations of healthcare providers, and reflections on birth planning.ConclusionsParticipants sought various support and interactions with healthcare providers, both helpful and unhelpful, with nulliparous women of advanced maternal age undertaking various preparations with the intention of a positive childbirth experience. Participants were seeking support from friends, along with conducting their own independent research and activities.Implications for practiceIt is evident that more and more women in developed countries are delaying having children into their late thirties and over, and these women report various levels of support from health practitioners. Healthcare professionals have the potential to foster more trustful relationships and empowering interactions with women, provide various resources regarding childbirth preparation, and sensitive birth planning assistance that supports women's agency along with managing risk. Guidelines based on this and other research in managing the antenatal care of women of advanced maternal age would ensure consistency, particularly in terms of risk management and childbirth.     

Is advanced maternal age an independent risk factor for uteroplacental insufficiency?

OBJECTIVE: To determine whether maternal age 35 years or older is an independent risk factor for uteroplacental insufficiency and thus an independent indication for antepartum testing. STUDY DESIGN: A retrospective cohort analysis was performed of all deliveries at Los Angeles County-University of Southern California Women's and Children's Hospital between August 1, 1995, and September 1, 2003. Women with documented indications for antepartum testing, fetal anomalies, or delivery prior to 34 weeks were excluded from analysis. Markers of uteroplacental insufficiency included stillbirth, birth weight less than the 10th percentile, fetal distress, cesarean section for fetal distress, oligohydramnios, meconium passage, and 5-minute Apgar score less than 7. RESULTS: Indications for antepartum testing were significantly more common in women 35 years or older (33.2% versus 27.0%). After excluding women with indications for antepartum testing, anomalous fetuses, and women delivering prior to 34 weeks, stillbirth was twice as common in women 35 years and older. However, among stillbirths, growth restriction occurred with similar frequency in the older (28.6%) and younger (25.0%) cohorts. Among live births, 2 markers of uteroplacental insufficiency, intrapartum fetal distress (5.7% versus 4.1%) and cesarean delivery for fetal distress (4.0% versus 2.4%) were significantly more common in the older cohort. All other markers of uteroplacental insufficiency were observed with similar frequency in the 2 groups. CONCLUSIONS: After excluding women with other indications for antepartum testing, fetal anomalies, and delivery prior to 34 weeks, stillbirth was twice as common in women 35 years of age or older as in those younger than 35 years. The increased rate of stillbirth does not appear to be explained by a higher rate of uteroplacental insufficiency.     

Would it be too late? A retrospective case–control analysis to evaluate maternal–fetal outcomes in advanced maternal age

Purpose

To evaluate maternal–fetal outcomes in women of advanced maternal age (AMA; >35 years old) and women of physiological maternal age as controls (C; <35 years old).

Methods

Single-center, retrospective case–control analysis, from January 1 to December 31, 2013. For each group, we evaluated obstetric history, number of twin pregnancies, delivery mode, incidence of obstetric diseases and neonatal outcomes (5-min Apgar score, neonatal weight, meconium stained fluid rate, admission to the neonatal intensive care unit rate, and incidence of congenital malformations). Data are presented as n (%) and analyzed with χ ² test and Fisher exact test (when required). A p value < 0.05 was considered statistically significant. Moreover, we calculated the odds ratio (OR), with confidence interval (CI) at 95 %.

Results

We enrolled 1,347 pregnant women, 210 (15.6 %) in AMA and 1,137 (84.4 %) C. AMA patients showed a higher rate of previous (anamnestic) spontaneous abortion (SA; p = 0.001; OR = 2.10) and previous (anamnestic) voluntary pregnancy termination (p = 0.022; OR = 1.59), iterative cesarean section (p = 0.026; OR = 2.33), SA (p = 0.001; OR = 12.82), preterm delivery (p = 0.001; OR = 69.84), congenital malformations (p = 0.036; OR = 3.94). In C there was a greater number of nulliparous (p = 0.009; OR = 0.52) and vaginal deliveries (p = 0.025; OR = 0.41). There were not any statistically significant differences between the two groups for twin pregnancies (p = 0.862; OR = 0.97), first cesarean section (p = 0.145; OR = 0.95), other obstetric diseases and neonatal outcomes.

Conclusion

AMA could be considered an important risk factor only for SA and PTD and does not influence neonatal outcomes except for congenital malformations.     

Concerns for decreased foetal movements in uncomplicated pregnancies – Increased risk of foetal growth restriction and stillbirth among women being overweight,advanced age or smoking

Introduction.?We aimed to determine whether the clinical characteristics of women in uncomplicated pregnancies presenting with decreased foetal movements (DFMs) would help target subgroups of women at the highest risk. Furthermore, we also aimed whether DFMs in complicated pregnancies identified the additional needs for intensified management.

Methods.?Singleton third trimester pregnancies (n?=?2374) presenting with DFMs from June 2004 through October 2005 were prospectively registered in 14 delivery units in Norway. Among pregnancies that were uncomplicated until registration for DFMs, cases with good outcomes (birth weight between 10th and 90th percentile, term delivery and live-born child) were compared with cases with adverse outcomes.

Results.?In uncomplicated pregnancies, maternal overweight, advanced age and smoking identified subgroups of cases at increased risk of foetal growth restriction and stillbirth. DFMs of longer duration, in particular the perceived absence of movements, identified cases at increased risk of stillbirth, irrespective of other maternal characteristics. When women with complicated pregnancies reported DFMs, additional indications for follow-up were found in 1/3 of cases.

Conclusions.?Maternal overweight, advanced age, smoking and the duration of DFMs are the characteristics that help in identifying pregnancies that should be targeted for intensified management. Time matters and knowledge-based information are needed to improve foetal health.     

Risk factors for HIV infection among women in Dodoma region,Tanzania

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Seroprevalence and risk factors for cytomegalovirus infection among pregnant women in southern Taiwan, 2014–2015

ObjectiveTo investigate the seroprevalence of and risk factors for cytomegalovirus (CMV) infection among pregnant women in southern Taiwan.Materials and methodsFrom 2014 to 2015, pregnant women undergoing their first prenatal care visit participated in this study at Kaohsiung Chang Gung Memorial Hospital and Chiayi Chang Gung Memorial Hospital. A serologic test was performed for anti-CMV IgG/IgM. Transabdominal amniocentesis was scheduled for those with seropositive anti-CMV IgM. Extraction of CMV DNA was performed via real-time polymerase chain reaction (PCR). Maternal sociodemographic characteristics and risk factors for CMV seropositivity were analyzed.ResultsA total of 539 pregnant women undergoing their first prenatal visit were included. Eighty-three pregnant women were excluded for delivering at other hospitals. The overall seroprevalence rate of anti-CMV IgG in the remaining 456 cases was 87.28%. The seroprevalence rates of anti-CMV IgG(+)/IgM(+) and IgG(+)/IgM(?) were 1.32% and 85.96%, respectively. According to the anti-CMV IgG avidity test, only 3 pregnant women (0.65%) had primary CMV infection. Two of them underwent amniocentesis, and the results for both were negative for CMV DNA. According to the logistic regression analysis, the seropositivity of anti-CMV IgG was significantly associated with maternal age ≥30 (adjusted OR = 2.08, 95% CI: 1.10–3.94, p = 0.025) and the seropositivity of anti-CMV IgM was significantly associated with gestational weeks ≥37 when delivery (adjusted OR = 7.81, 95% CI: 1.23–49.58, p = 0.029).ConclusionIn southern Taiwan, among pregnant women, the CMV seroprevalence was high (87.28%), but the rate of primary CMV infection was very low (0.65%). Pregnant women aged more than 30 years had a significant risk of CMV seropositivity.     

Cervical Pap screening among Israeli women, 2005–2010

Purpose

This study describes the distribution and the trends of cervical abnormalities in Israel, based on Pap smear results.

Methods

A retrospective analysis of cervical smears received by the Central Pathology Laboratory of Maccabi Healthcare Services between January 2005 and December 2010.

Results

In total, 711,541 Pap smears were screened in the study period. Cytological abnormalities were observed in 4.78 % of the total smears screened. An increase was observed in the rate of positive results from 2.63 % in 2005 to 6.78 % in 2010 (p = 0.0026). The cervical abnormalities in the study period distributed as follows: atypical squamous cell (ASC)—2.72 %, low-grade squamous intraepithelial lesion (LSIL)—1.54 %, high-grade squamous intraepithelial lesion (HSIL)—0.34 %, squamous cell carcinoma—0.01 %, atypical glandular cells (AGC)—0.10 %, adenocarcinoma in situ (AIS)—0.06 % and invasive adenocarcinoma—0.01 %. The increase was statistically significant for ASC (p = 0.0028), LSIL (p = 0.0069) and for HSIL (p = 0.0260). The mean ages at diagnosis of women with ASCUS, LSIL, HSIL, squamous cell carcinoma, AGC, AIS and adenocarcinoma were 37.8, 33.2, 38.6, 55.4, 41.1, 49.9 and 57.1 years, respectively.

Conclusions

The increase in the rate of squamous cell abnormalities demonstrated in this study emphasizes the need of implementing an education and a screening program among Israeli women. HPV vaccine, sexual behavior, cytology performance and HPV test are primary and secondary prevention tools which may reduce morbidity and mortality in the future. In addition, based on the age at diagnosis of the different pathologies, the age group in which Pap test is performed in Israel should be expanded from 35–54 to 25–65 years.     

The changing patterns of abortion among married women in China, 1984–2005

Objective

To identify changing levels and patterns of abortion in China among married women, and the determinants of these changes.

Study design

Based on data from four nationwide surveys conducted by the Chinese National Population and Family Planning Commission in 1988, 1997, 2001 and 2006, this paper analyzed abortion rates by age, residence, and education. To minimize recall error, only the pregnancy history of the 5–10 years before the survey was used.

Results

Overall abortion levels in China fluctuated in the period 1970–1990, but declined markedly after 1991. The profile of women resorting to abortion has shifted from older, rural, less educated women, toward younger, urban, more educated women, at a rate beyond the change in composition of the population as a whole. Young, urban, educated women are also the demographic group more likely to employ “user controlled”, short term methods.

Conclusion

The findings are consistent with a gradual shift in the Chinese family planning programme, increasingly meeting the principles of the International Conference on Population and Development, which calls for making contraception accessible, and thereby helping women avoid recourse to abortion. Future reproductive health programmes should allow women more autonomy in socio-economic factors affecting their reproductive health.     

Canadian women’s attitudes toward noninvasive prenatal testing of fetal DNA in maternal plasma*

Objective: To determine the perceptions and attitudes of Canadian women to Noninvasive Prenatal Testing of fetal DNA.

Study design: A designed questionnaire was administered to women attending the outpatient antenatal clinic at a tertiary urban hospital. Attitudes to current and new prenatal screening modalities were assessed using a five-point Likert scale. Bowker’s test of symmetry was used to compare individual responses regarding the two screening modalities. Changes in women’s responses pre- and post-delivery were also compared.

Results: One hundred and twenty-nine women were enrolled in this study. 88% of women state that they would perform prenatal screening via fetal DNA in the maternal plasma if available. When compared to conventional screening, significantly less women believe that the NIPT should be available upon request for non-medical traits (36.4% versus 60.4%, p?<?0.001). When compared to their answer before delivery, more women agreed that screening with fetal DNA in maternal plasma could be used in a negative way to select for desired non-medical traits such as gender.

Conclusions: The use of fetal DNA in the maternal plasma is widely accepted in our Canadian population as a future method of noninvasive prenatal screening despite recognition of certain ethical concerns. This information can be used when implementing new genetic screening programs.     

The impact of advanced maternal age (≥40 years) on birth outcomes among triplets: a population study

Objective The objective was to determine the impact of advanced maternal age on the birth outcomes of triplet gestations.Study design A retrospective cohort study on 15,795 triplets born in the United States from 1995 to 1997. The generalized estimating equations framework was used to generate relative risks after capturing the effect of sibling correlations within triplet clusters.Results There was a 40% higher likelihood for stillbirths among older gravidas (40 years) as compared to younger mothers (20–29 years) although this was statistically non-significant. By contrast, we noted a significantly lower level of neonatal mortality (OR=0.36, 95% CI=0.19–0.67), perinatal mortality (OR=0.53; 95% CI=0.32–0.89) and infant mortality (OR=0.37; 95% CI=0.20–0.67) among older mothers.Conclusion Our findings demonstrate a shifting phenomenon whereby a higher level of intra-uterine demise was compensated by a higher rate of extra-uterine survival among triplets born to older mothers.     

The relationship between maternal–fetal attachment and maternal self-efficacy in Iranian women: a prospective study

Introduction: This prospective study was conducted to determine the relationship between maternal–fetal attachment and maternal self-efficacy. Maternal self-efficacy contributes significantly to the mental health of the mother and infant. Maternal–fetal attachment facilitates maternal role attainment and might improve maternal self-efficacy.

Methods: This study was conducted on 242 women. The data collection tools used included a socio-demographic and obstetric questionnaire, Cranley’s Maternal–Fetal Attachment Scale, the Edinburgh Postnatal Depression Scale and the Maternal Self-Efficacy Scale. A multivariate linear regression was used to estimate the extent to which maternal–fetal attachment affects maternal self-efficacy.

Results: Pearson’s correlation test showed a moderate but significant positive correlation between maternal–fetal attachment and self-efficacy (r = 0.48, P < 0.001). The highest correlation with self-efficacy was observed in the domain of ‘differentiation of self from fetus’ (r = 0.43) and the lowest in the domain of ‘giving of self’ (r = 0.25). According to the multivariate linear regression, the domain of ‘Interaction with fetus’ had a significant relationship with maternal self-efficacy (P = 0.009).

Conclusion: Maternal–fetal attachment would appear to be a factor related to postpartum maternal self-efficacy which suggests identifying and supporting women with low self-efficacy may increase maternal–fetal attachment and thereby maternal self-efficacy.     

The future of prenatal diagnosis: rapid testing or full karyotype? An audit of chromosome abnormalities and pregnancy outcomes for women referred for Down's Syndrome testing

OBJECTIVE: To assess the implications of a change in prenatal diagnosis policy from full karyotype analysis to rapid trisomy testing for women referred primarily for increased risk of Down's Syndrome. DESIGN: Retrospective collection and review of data. SETTING: The four London Regional Genetics Centres. POPULATION: Pregnant women (32,674) in the London area having invasive prenatal diagnosis during a six-year three-month period. METHODS: Abnormal karyotypes and total number of samples referred for raised maternal age, raised risk of Down's Syndrome following serum screening or maternal anxiety were collected. Abnormal karyotypes detected by molecular trisomy detection were removed, leaving cases with residual abnormal karyotypes. These were assessed for their clinical significance. Pregnancy outcomes were ascertained by reviewing patient notes or by contacting obstetricians or general practioners. MAIN OUTCOME MEASURES: Proportion of prenatal samples with abnormal karyotypes that would not have been detected by rapid trisomy testing, and the outcome of those pregnancies with abnormal karyotypes. RESULTS: Results from 32,674 samples were identified, of which 24,891 (76.2%) were from women referred primarily for Down's Syndrome testing. There were 118/24,891 (0.47%) abnormal sex chromosome karyotypes. Of the samples with autosomal abnormalities that would not be detected by rapid trisomy testing, 153/24,891 (0.61%) were in pregnancies referred primarily for Down's Syndrome testing. Of these, 98 (0.39%) had a good prognosis (46/98 liveborn, 3/98 terminations, 1/98 intrauterine death, 1/98 miscarriage, 47/98 not ascertained); 37 (0.15%) had an uncertain prognosis (20/37 liveborn, 5/37 terminations; 12/37 not ascertained) and 18 (0.07%) had a poor prognosis (1/18 liveborn, 2/18 miscarriage, 11/18 terminations, 4/18 not ascertained). CONCLUSIONS: For pregnant women with a raised risk of Down's Syndrome, a change of policy from full karyotype analysis to rapid trisomy testing would result in the failure to detect chromosome abnormalities likely to have serious clinical significance in approximately 0.06% (1 in 1659) cases. However, it should be noted that this figure may be higher (up to 0.12%; 1 in 833) if there were fetal abnormalities in some of the pregnancies in the uncertain prognosis group for which outcome information was not available.