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)     

Maternal age over 40 years and pregnancy outcome: a hospital-based survey

Objective: Increased risk for adverse pregnancy outcomes with advancing maternal age has been described but the strength of association remains debated, particularly in presence of confounding factors such as parity, twin pregnancy and pregnancy from assisted reproductive technologies. The aim of this study was to evaluate pregnancy outcomes in a large cohort of women aged over 40 years. The hypothesis was that advanced maternal age may be an independent risk factor for adverse pregnancy outcome.

Study design: We reviewed the clinical records of 56,211 women who delivered at Sant’Anna University Hospital, Turin, Italy, in the period between 2009 and 2015. Of these, 3798 women aged over 40 years were divided into two age groups (40???44 years and ≥45 years). Women of any parity, with singleton or twin pregnancies, or with assisted reproductive technology pregnancies were included. Women aged less than 40 years were considered as controls. Primary outcome measures were maternal and perinatal complications. Comparisons were performed using Chi-square test and Fisher’s exact test. Univariate analysis and logistic regression analysis were performed to test the possible independent role of maternal age as a risk factor for adverse pregnancy outcome.

Results: Maternal age was an independent risk factor for gestational diabetes (age 40–44 years: odds ratios (OR) 2.10, 95% CI 1.80–2.45; age ≥45 years: OR 2.83, 95% CI 1.79–4.46) and early-onset preeclampsia (age 40–44 years: OR 2.10, 95% CI 1.63–2.70; age ≥45 years: OR 3.16, 95% CI 1.68–5.94). The risk for placenta praevia was higher in the women aged 40–44 years (OR 1.87, 95% CI 1.36–2.57). Neonatal outcomes were similar among groups, except for the rate of birth weight less than 2500?g, which was higher in women aged 40–44 years (OR 1.27, 95% CI 1.12–1.42). However, older women showed an overall higher incidence of preterm birth.

Conclusions: Maternal age over 40 years is an independent risk factor for adverse pregnancy outcomes, particularly for the mother. Pregnancies in women over 40 years should be considered at risk and carefully monitored with individualized care protocols.     

Maternal age ≥45 years and maternal and perinatal outcomes: A review of the evidence

Objective

to examine the evidence in relation to very advanced maternal age (≥45 years) and maternal and perinatal outcomes in high-income countries.

Background

this review was conducted against a background of increasing fertility options for women aged ≥=45 years and rising birth rates among this group of women.

Methods

established health databases including SCOPUS, MEDLINE, CINAHL, EMBASE and Maternity and Infant Care were searched for journal papers, published 2001–2011, that examined very advanced maternal age (VAMA) and maternal and perinatal outcomes. Further searches were based on references found in located articles. Keywords included a search term for maternal age ≥45 years (very advanced maternal age, pregnancy aged 45 years and older) and a search term for maternal complications (caesarian section, hypertension, pre-eclampsia, gestational diabetes) and/or adverse perinatal outcome (preterm birth, low birth weight, small for gestational age, stillbirth, perinatal death). Of 164 retrieved publications, 10 met inclusion criteria.

Data extraction

data were extracted and organised under the following headings: maternal age ≥45 years; maternal characteristics such as parity and use of artificial reproductive technology (ART); and pre-existing maternal conditions, such as diabetes and hypertension. Additional headings included: gestational conditions, such as pre-eclampsia and gestational diabetes (GDM); and perinatal outcomes, including fetal/infant demise; gestational age and weight. Study quality was assessed by using the Critical Appraisal Skills Programme (CASP) guidelines.

Findings

this review produced three main findings: (1) increased rates of stillbirth, perinatal death, preterm birth and low birth weight among women ≥45 years; (2) increased rates of pre-existing hypertension and pregnancy complications such as GDM, gestational hypertension (GH), pre-eclampsia and interventions such as caesarian section; and (3) a trend of favourable outcomes, even at extremely advanced maternal age (50–65 years), for healthy women who had been screened to exclude pre-existing disease.

Key conclusions

although there is strong evidence of an association between very advanced maternal age and adverse maternal and perinatal outcomes, the absolute rate of stillbirth/perinatal death remains low, at less than 10 per 1000 births in most high-income countries. Therefore, although women in this age group encounter greater pregnancy risk, most will achieve a successful pregnancy outcome. Best outcomes appear to be linked to pre-existing maternal health, and pregnancy care at tertiary centres may also contribute. This information should be used to counsel women aged ≥45 years who are contemplating pregnancy.     

Differential effect of mode of conception and infertility treatment on fetal growth and prematurity

Objectives To examine perinatal outcomes in pregnancies conceived by different methods: fertile women with spontaneous pregnancies, infertile women who achieved pregnancy without treatment, pregnancies achieved by ovulation induction (OI) and in vitro fertilization or intra-cytoplasmic sperm injection (IVF/ICSI).

Methods Retrospective single-center cohort study including 200 fertile and 748 infertile women stratified according to infertility treatment. The outcome measurements were preterm delivery (PTD), small-for-gestational-age (SGA), gestational diabetes, placenta previa or preeclampsia.

Results The overall rate of pregnancy complications was significantly increased in all infertility groups regardless of the infertility treatment (adjusted odds ratio (OR): infertile without treatment 2.3 versus OI 2.2 versus IVF/ICSI 3.4). While PTD was mainly associated to IVF/ICSI (adjusted OR: infertile without treatment 1.3 versus OI 1.6 versus IVF/ICSI 3.3), SGA was significantly associated to both OI and IVF/ICSI (adjusted OR: infertile without treatment 1.9 versus OI 2.7 versus IVF/ICSI 2.6). All these associations remained statistically significant after adjusting by maternal age and twin pregnancy.

Conclusions This study confirms the higher prevalence of pregnancy complications in infertile women irrespectively of receiving infertility treatment or not, and further describes a preferential association of prematurity with IVF/ICSI, and SGA with treated infertility (OI and IVF/ICSI).     

The Impact of Bariatric Surgery on Assisted Reproductive Technology Outcomes: A Systematic Review

ObjectiveThere is a paucity of literature on the impact of bariatric surgery on artificial reproductive technology (ART) outcomes. This topic should be examined, given that most bariatric surgery candidates are of reproductive age and those with obesity are significantly more likely to experience poor fertility outcomes. This systematic review aimed to determine if bariatric surgery impacts ART outcomes and if effects vary between females and males.Data SourcesMEDLINE, EMBASE, SCOPUS, and the Cochrane Central Register of Controlled Trials were searched for English studies published between January 1978 and May 2021.Study SelectionStudies with participants who had received bariatric surgery and subsequently underwent ART (i.e., in vitro fertilization or intracytoplasmic sperm injection) were eligible for inclusion. Screening, data abstraction, and risk of bias assessment were conducted independently and in duplicate.Data Extraction and SynthesisOf the 279 articles screened for eligibility, 25 were sought for full text review, and 7 were included for analysis. Four studies (57%) examined ART interventions in females, while 3 (43%) examined interventions in males. Data on cumulative live birth rate (CLBR) was extracted for all 7 studies (N = 169). There were 50 live births with CLBRs ranging from 0.0% to 80.0%. Data on female secondary outcomes were varied. Data on male secondary outcomes were contradictory: 1 study indicated improved sperm parameters following bariatric surgery, while 2 showed decreased parameters, with certain participants seeing improvements after several months.ConclusionBariatric surgery prior to ART may have an impact on CLBRs; however, high-quality research is needed to delineate the direct effects of bariatric surgery on ART outcomes. Various sex-specific outcomes should be considered prior to recommending ART after bariatric surgery. Future research should determine the optimal type of bariatric surgery and timing of ART following bariatric surgery.     

基础焦虑状态对IVF/ICSI妇女妊娠结局影响的系统评价

目的:研究施行体外受精/卵细胞浆内单精子注射(IVF/ICSI)的不孕症妇女基础焦虑状态对其妊娠结局的影响。方法:全面检索与研究目的相关文献,根据纳入与排除标准选择原始研究。经两人独立提取数据,对文献进行质量评价。采用RevMan5.0软件对所纳入的研究进行异质性分析,并对计量资料进行合并。结果:①状态焦虑对IVF/ICSI妊娠结局有负性影响(WMD状态焦虑=-2.51,95%CI-4.58～-0.44);②特质焦虑对IVF/ICSI妊娠结局无显著影响(WMD特质焦虑=2.57,95%CI-0.58～7.87);③漏斗图分析未提示不对称分布,故纳入文献无发表偏倚。结论:对IVF/ICSI的不孕症妇女,在开始治疗前对患者进行心理干预可能改善治疗结局;小样本的研究合并后可以看出特质焦虑对IVF/ICSI妊娠结局并无显著影响。     

Hysteroscopic Resection of Endometrial Polyps and Assisted Reproductive Technology Pregnancy Outcomes Compared with No Treatment: A Systematic Review

Endometrial polyps are frequently encountered in the uterine cavity of infertile women. There is much debate regarding the treatment of endometrial polyps in patients who are undergoing assisted reproductive technology (ART). A systematic review was performed by searching PubMed, Embase, and the Cochrane Library for retrospective or prospective studies that compared the effect of hysteroscopic resection of polyps with no treatment on pregnancy outcomes of patients who underwent ART. The primary outcomes were clinical pregnancy, live birth, miscarriage, and implantation rates after ART. Eight studies with a total of 2267 patients were included. The results showed that hysteroscopic resection of endometrial polyps (mean size <2 cm) was associated with an increased rate of clinical pregnancy in patients who underwent intrauterine insemination. No clear benefit was observed for clinical pregnancy, live birth, miscarriage, or implantation rates in patients who underwent in vitro fertilization/intracytoplasmic sperm injection cycles. In conclusion, the effect of hysteroscopic polypectomy on pregnancy outcomes of patients who have undergone ART remains unclear. More prospective, randomized controlled trials are warranted to determine appropriate treatment.     

A systematic review investigating psychosocial aspects of egg sharing in the United Kingdom and their potential effects on egg donation numbers

This review aims to provide an up-to-date knowledge of the psychosocial aspects of egg donation from the perspectives of the egg share donor and their recipient. It explores the motives, experiences and attitudes of egg sharers and their views towards donor anonymity and disclosure. Conclusions are made on how these findings can guide clinical practice and improve egg sharing numbers. A systematic search of peer-reviewed journals of four computerized databases was undertaken. Eleven studies were included in the review. Psychosocial aspects towards donation were positive from the egg share donor and recipient. Concerns raised were whether participating in the egg sharing scheme would impact on their success rates, as well as frustration expressed by a minority regarding the lack of knowledge of egg sharing outside of fertility clinics. The 2005 legislative changes in the UK have not caused the anticipated dramatic decrease in egg donation; however, oocyte donation still falls short of demand. Egg sharing provides a practical option for more patients to access IVF, whilst also providing more donor oocytes. Improved information provision will result in greater awareness of egg sharing, with the potential to recruit more donors and meet the needs of recipients currently on long waiting lists.     

Influence of Laboring People's Mobility and Positional Changes on Birth Outcomes in Low-Dose Epidural Analgesia Labor: A Systematic Review with Meta-Analysis

Introduction

Freedom of movement has been identified as a key issue for pregnant individuals during the birthing process, even if they opt for epidural analgesia, which has relegated people to more static positions during birth for many years. The aims of this systematic review were to evaluate the influence of mobility and positional changes on perinatal and neonatal outcomes in people in labor with epidural analgesia, describe the range of movement interventions used during the first and second stage of labor, and describe the level of motor blockade among people with low-dose epidural analgesia.

Methods

Bibliographic databases (Web of Science, Cochrane, CINAHL) were consulted from December 2020 to January 2021. The articles selected were clinical trials and observational or analytical studies, the subject of which was mobilization during labor in people with epidural analgesia. The outcome measures were mode of birth, duration of labor, and extrauterine adaptation after birth. A narrative synthesis was used to describe the types of movements interventions employed during the stages of labor and the level of motor blockade among people with low-dose epidural analgesia.

Results

Ten articles were selected (8 clinical trials, one cross-sectional study, and one quasiexperimental study), with a total sample of 6086 individuals. A meta-analysis showed nonsignificant results between groups for mode of birth (relative risk [RR], 1.00; 95% CI, 0.87-1.14), duration of labor (RR, 1.64; 95% CI, -34.57 to 37.86), and extrauterine adaptation after birth (RR, 0.86; 95% CI, 0.39-1.93). There was heterogeneity among studies in the type of movement interventions used during the first and second stage of labor.

Discussion

Although no clear benefit was observed for mobilization in epidural labor, no detrimental effects were found either, so perinatal care providers should encourage mobilization if the laboring person so desires, throughout the entire childbirth process.     

Systematic Review of the Literature on Postpartum Care: Effectiveness of Postpartum Support to Improve Maternal Parenting,Mental Health,Quality of Life,and Physical Health

Abstract: Background: Postpartum support is recommended to prevent infant and maternal morbidity. This review examined the published evidence of the effectiveness of postpartum support programs to improve maternal knowledge, attitudes, and skills related to parenting, maternal mental health, maternal quality of life, and maternal physical health. Methods: MEDLINE, Cinahl, PsycINFO, and the Cochrane Library were searched for randomized controlled trials of interventions initiated from immediately after birth to 1 year in postnatal women. The initial literature search was done in 1999 and was enhanced in 2003 and 2005. Studies were categorized based on the the above outcomes. Data were extracted in a systematic manner, and the quality of each study was reviewed. Results: In the 1999 search, 9 studies met the inclusion criteria. The 2003 and 2005 searches identified 13 additional trials for a total of 22 trials. Universal postpartum support to unselected women at low risk did not result in statistically significant improvements for any outcomes examined. Educational visits to a pediatrician showed statistically significant improvements in maternal‐infant parenting skills in low‐income primiparous women. In women at high risk for family dysfunction and child abuse, nurse home visits combined with case conferencing produced a statistically significant improvement in home environment quality using the HOME (Home Observation for Measurement of the Environment) program. Similarly, in women at high risk for either family dysfunction or postpartum depression, home visitation or peer support, respectively, produced a statistically significant reduction in Edinburgh Postnatal Depression Scale scores (difference ‐ 2.23, 95% CI –3.72 to –0.74, p= 0.004; and 15.0% vs 52.4%, OR 6.23, 95% CI 1.40 to 27.84, p= 0.01, respectively). Educational programs reduced repeat unplanned pregnancies (12.0% vs 28.3%, p= 0.003) and increased effective contraceptive use (RR 1.35, 95% CI 1.09 to 1.68, p= 0.007). Maternal satisfaction was higher with home visitation programs. Conclusions: No randomized controlled trial evidence was found to endorse universal provision of postpartum support to improve parenting, maternal mental health, maternal quality of life, or maternal physical health. There is some evidence that high‐risk populations may benefit from postpartum support. (BIRTH 33:3 September 2006)     

Obstetric outcomes of twin pregnancies at advanced maternal age: A retrospective study

Objective

To evaluate obstetric outcomes in twin pregnancies of advanced maternal age (≥35 years).

Interventions to Try to Prevent Preterm Birth in Women With a History of Conization: A Systematic Review and Meta-analyses

Objectives

The most effective preterm birth (PTB) intervention is unknown for women who are at risk of PTB due to a history of conization. The objective of this systematic review was to determine whether PTB interventions, progesterone, cerclage, and pessary decrease the risk of PTB compared to no treatment in singleton—and separately in twin—pregnancies of women with history of conization.

The cost of preterm birth and cesarean section as a result of infertility and its treatment: A review

Infertility, irrespective of receipt of fertility treatment, is associated with an increased risk of adverse pregnancy outcomes, including cesarean section (CS) and preterm birth (PTB). These complications are associated with significant physical, mental, emotional, social, and financial costs to individuals, healthcare systems, and society at large. Although multiple pregnancy is one of the most significant contributors to the elevated CS and PTB rates in women receiving fertility treatment, singleton pregnancy is also at an increased risk of these outcomes. Single embryo transfer policies through publicly funded in vitro fertilization programs have demonstrated beneficial health outcomes and cost savings. Low-dose aspirin prophylaxis may be considered for PTB reduction in patients with infertility. Finally, upstream prevention strategies such as lifestyle modification and social policies to address the underlying needs for fertility treatment may also beneficially impact both CS and PTB rates.