Pregnancy outcome at extremely advanced maternal age

Coagulation and fibrinolytic indices during the first trimester of pregnancy in women with polycystic ovary syndrome: a preliminary study

OBJECTIVE

To evaluate the levels of coagulation and fibrinolytic markers during the first trimester of pregnancy in women with polycystic ovary syndrome (PCOS) and determine the effects of PCOS and obesity on the levels of these hemostatic markers.

METHODS

A cross-sectional study was conducted in Beijing, China, on women with PCOS (n = 50), healthy women (n = 50), pregnant women with PCOS (n = 50), and healthy pregnant women (n = 50) at 12 weeks of pregnancy. Coagulation and fibrinolytic parameters were measured.

RESULTS

The interaction between PCOS and pregnancy appears to exert effects on the activities of coagulation factors VIII and X. The interaction between PCOS and obesity also seems to affect the level of von Willebrand factor.

CONCLUSIONS

Pregnant women with PCOS, especially women who are obese, are observed to be in a more prohemostatic state during the first trimester.

Pregnancy outcome at advanced maternal age in a group of African women in two teaching Hospitals in Yaounde, Cameroon

Introduction

Women older than 40 years have been termed “advanced maternal age” and considered to be at risk of adverse pregnancy outcome. This study aimed to examine the obstetrical outcomes among primiparous and multiparous African advanced maternal age women.

Methods

We conducted a retrospective cohort study study at two teaching hospitals at Yaounde, Cameroon. From the hospital records, obstetrical characteristics of 585 consecutive women aged 40 or above who delivered from January 2007 to December 2011 were compared with those of 1816 younger mothers aged 20 to 29 years as control cases. Associations between maternal age and selected obstetrical variables were assessed with the contigency X² test or two-tailed Fisher exact test.

Results

Primiparous and multiparous advanced maternal age were more likely to undergo cesarean delivery than were their younger counterparts (38.5% vs 13.5%, RR=2.85, p<0.05 and 16.1% vs 9.1%, RR=1.76, p<0.05). Older primiparous women had similar perinatal outcomes than their younger counterparts. Older multiparous women had increased incidence of preeclampsia/eclampsia (2.4% vs 0.6%, RR=4, p<0.01); antepartum hemorrhage (1.8% vs 0.8%, RR=2.25, p<0.01); fetal distress (3.5% vs 1.3%, RR=2.69, p<0.01); fetal death (3.5% vs 1.6%, RR= 2.18, p<0.05); postpartum hemorrhage (2.4% vs 1.2%; RR=2, p<0.05); preterm delivery (12% vs 9.2%, RR=1.30, p<0.05); low birth weight (11% vs 7.7%, RR=1.42, p<0.05); admission to special care neonatalogy unit(14.1% vs 10.2%, RR=1.38, p<0.05); low Apgar scores at 1min and 5min; and perinatal mortality (3.5% vs 1.6, RR=2.18, p<0.05).

Conclusion

Advanced maternal age women are at higher risk to cesarean delivery. Increased risk of antepartum and intra partum complications among multiparous advanced maternal age women were associated to adverse perinatal outcome. Our results are in concordance with the view that increased risk of adverse perinatal outcome with advanced maternal age is indirectly related to age through the increased risk of obstetrical complications associated with age.

Very advanced maternal age and morbidity in Victoria, Australia: a population based study

BACKGROUND

In Australia, approximately 0.1% of births occur to women 45 years or older and this rate has been increasing in recent years. There are however, few population based studies examining perinatal outcomes among this age group. The aim of this study was to determine the maternal and perinatal outcomes of pregnancies in women aged 45 years or older compared to women aged 30-34 years.

METHODS

Data on births at 20 or more weeks' gestation were obtained from the Victorian Perinatal Data Collection for the years 2005 and 2006. We examined selected maternal and perinatal outcomes for women of very advanced maternal age (VAMA) aged 45 years or older (n = 217) and compared them to women aged 30-34 years (n = 48,909). Data were summarised using numbers and percentages. Categorical data were analysed by Chi-square tests and Fisher's exact test. Comparisons are presented using unadjusted odds ratios, 95 percent confidence intervals (CIs) and p-values.

RESULTS

Women aged 45 years and older had higher odds of gestational diabetes (OR 2.05; 95% CI 1.3-3.3); antepartum haemorrhage (OR 1.89; 95% CI 1.01-3.5), and placenta praevia (OR 4.88; 95% CI 2.4-9.5). The older age-group also had higher odds of preterm birth between 32-36 weeks (OR 2.61; 95% CI 1.8-3.8); low birth-weight (<2,500 gr) (OR 2.22; 95% CI 1.5-3.3) and small for gestational age (OR 1.53; 95% CI 1.0-2.3). Stratified analysis revealed that VAMA was most strongly associated with caesarean section in primiparous women (OR 8.24; 95% CI 4.5, 15.4) and those using ART (OR 5.75; 95% CI 2.5, 13.3), but the relationship persisted regardless of parity, ART use and plurality. Low birthweight was associated with VAMA only in first births (OR 3.90; 95% CI 2.3, 6.6), while preterm birth was more common in older women for both first (OR 3.13; 95% CI 1.8, 5.3) and subsequent (OR 2.08; 95% CI 1.2, 3.5) births, and for those having singleton births (OR 2.11; 95% CI 1.3, 3.4), and those who did not use ART (OR 2.10; 95% CI 1.3, 3.4). Preterm birth was very common in multiple births and following ART use, regardless of maternal age.

CONCLUSIONS

This study demonstrates that women aged 45 years and older, in Victoria, Australia, have higher rates of pregnancy and perinatal complications, compared to women aged 30-34 years.

Maternal age and birth defects after the use of assisted reproductive technology in Japan, 2004-2010

BACKGROUND

Older mothers are becoming more common in Japan. One reason for this is the widespread use of assisted reproductive technology (ART). This study assesses the relationship between maternal age and the risk of birth defects after ART.

METHODS

Nationwide data on ART between 2004 and 2010 in Japan were analyzed. Diseases that were classified as code Q00-Q99 (ie, congenital malformations, deformations, and chromosomal abnormalities) in the International Classification of Diseases, tenth edition, were selected. There were 219,185 pregnancies and 153,791 live births in total ART. Of these, 1943 abortions, stillbirths, or live births with birth defects were recorded. Percentage of multiple birth defects in total birth defects, the prevalence, crude relative risk and 95% confidence interval per 10,000 pregnancies and per 10,000 live births were analyzed according to the maternal age class (ie, 25-29, 30-34 (reference), 35-39, and 40+ years).

RESULTS

Multiple birth defects were observed among 14% of the 25-29 year old class, and 8% among other classes when chromosomal abnormalities were excluded. The prevalence of chromosomal abnormalities per pregnancy and per live birth became significantly and rapidly higher in mothers in the age classes of 30-35 and 40+ years. Nonchromosomal birth defects per pregnancy decreased linearly with advanced maternal age, while the number of nonchromosomal birth defects per live birth formed a gradual U-shaped distribution. The prevalence per pregnancy of congenital malformations of the nervous system was significantly lower with advanced maternal age. The relative risk per live birth was significant regarding congenital malformations of the circulatory system for a maternal age of 40+ years. Some other significant associations between maternal age and birth defects were observed.

CONCLUSION

Maternal age is associated with several birth defects; however, older maternal age in itself does not produce noticeable extra risk for nonchromosomal birth defects overall.

Association between Endocrine Disrupting Phenols in Colostrums and Maternal and Infant Health

Bisphenol A (BPA) and alkylphenols (APs) are well-known endocrine disrupting chemicals (EDCs) which may threat the next generations' health. We performed biomonitoring of these phenols in colostrums to assess risk of the phenols in breast-fed neonates. Study subjects were the lactating mothers who delivered babies within 2 weeks (N = 325; 30.67 ± 3.45 years) and their neonates (N = 326; embryonic period, 39.1 ± 1.5 weeks). BPA, nonylphenol (NP), and octylphenol (OP) in colostrums were quantified with LC/MS/MS. Information for environmental exposure sources of the phenols was obtained by questionnaires. As results, median level of BPA in colostrums was 7.8 ng/mL, while most NP or OP was not detected. Regarding health risks of phenols, levels of total NP in colostrums were elevated among sick mothers with toxemia, thyroid disorders, gastritis, and so forth than health mothers (3.51 ± 4.98 versus 2.04 ± 3.71 ng/mL, P = 0.02). Dairy products intake and detergents use were positively correlated with total BPA levels (Ps < 0.05). In conclusion, we estimate most neonates who are exposed to BPA rather than NP or OP via colostrums and recommend continuous biomonitoring of the phenols to clarify their suspected health risk on neonates and pregnant or gestation mothers.

Association between maternal age and birth defects of unknown etiology: United States, 1997-2007

BACKGROUND

Birth defects affect 3% of babies born, and are one of the leading causes of infant mortality. Both younger and older maternal age may pose increased risks for certain birth defects. This study assessed the relationship between maternal age at the estimated delivery date and the risk for birth defects.

METHODS

Data were obtained from the National Birth Defects Prevention Study, a population-based case-control study including mothers across 10 states. Maternal age was stratified into six categories: <20, 20 to 24, 25 to 29, 30 to 34, 35 to 39, and ≥40 years, and also analyzed as a continuous variable. Logistic regression models adjusted formaternal race/ethnicity, education, body mass index (BMI), folic acid use, smoking, gravidity, and parental age difference were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

For maternal age <20 years, associations with total anomalous pulmonary venous return (aOR, 2.3; 95% CI, 1.3-4.0), amniotic band sequence (aOR, 2.4; 95% CI, 1.5-3.8), and gastroschisis (aOR, 6.1; 95% CI, 4.8-8.0) were observed. For the ≥40 year age group, associations with several cardiac defects, esophageal atresia (aOR, 2.9; 95% CI, 1.7-4.9), hypospadias (aOR, 2.0; 95% CI, 1.4-3.0), and craniosynostosis (aOR, 1.6; 95% CI, 1.1-2.4) were observed. Results using maternal age as a continuous variable were consistent with those that used categorized maternal age.

CONCLUSION

Elucidating risk factors specific to women ateither extreme of maternal age may offer prevention opportunities. All women should be made aware of prevention opportunities, such as folic acid supplementation, to reduce the occurrence of birth defects.

Maternal mortality

PURPOSE OF REVIEW

This review summarizes recent developments in maternal mortality surveillance, and draws from recent confidential mortality reports to suggest ways the anesthesiologist can contribute to safer systems of care.

RECENT FINDINGS

Maternal mortality rates appear to be static in much of the developed world, but are increasing in the USA. While improvements in ascertainment explain some of these trends, deferred childbearing, increasing population rates of coexisting disease, multifetal pregnancy, and emerging infections also contribute. Risk is markedly elevated among certain racial and ethnic minorities, due to a confluence of factors that includes behavior, biology, environmental exposures, social circumstances, and the quality of clinical care. Approximately 30-40% of maternal deaths are potentially preventable, and recent maternal mortality reviews suggest specific strategies that may improve outcomes for women suffering from the most common causes of death: cardiovascular disease, hemorrhage, hypertensive disorders of pregnancy, venous thromboembolism, infection, and other medical conditions.

SUMMARY

A growing number of countries and organizations have established systems for comprehensive maternal death surveillance and confidential review to ensure that each death counts and that the lessons learned are widely disseminated to improve future maternal safety.

What do we know about what happens to myometrial function as women age?

Much has been written about the effects of aging on reproductive function, especially female fertility. Much less is known about how aging may affect the contractility of the smooth muscle within the uterus, the myometrium. The myometrium is active through a woman’s entire life, not just during pregnancy. Here we will discuss briefly the contractile functions of the uterus and the changes it undergoes throughout the stages of a woman’s life from menstruation and the menopause, before evaluating the evidence for any changes in myometrial contractility and responses as women age, with a particular focus on women of advanced maternal age. We present original contractility analysis for the widest data set for human myometrium so far examined, and determine inherent spontaneous activity as well as responses to depolarisation and stimulation with oxytocin. Our data show that in the non-pregnant state there is a significant decrease in contractility for both spontaneous and depolarised-induced contractions, with age. We suggest that muscle atrophy and down regulation of Ca channels may account for this. Interestingly in pregnant myometrium we found a wide range of contractile ability between women and little evidence for decreased spontaneous activity between the ages of 25–40. Oxytocin responses appear to be more affected by aging, a finding that is consistent with previously reported clinical findings, and may partly be the result of membrane lipids such as cholesterol, increasing as women age. The marked differences between the age-related decline of force beyond age 30 in non-pregnant uterus, and the lack of difference in the pregnant state over this period, shows that the uterus retains its ability to respond to gestational hormones. The growth of the pregnant uterus and increase in content of myofibrillar proteins, may abolish any previous age-related force deficit. This finding is consistent with what is apparent for postmenopausal women in their 50s and 60s; that with the appropriate hormonal stimulation the uterus can allow an embryo to implant, and then without further intervention, carry the foetus to term. It is tempting therefore to speculate that unlike other well documented declines in female reproductive functions with age, the myometrium remains able to function into a woman’s 7th decade.

[Pregnancy in women aged 43 years or older: maternal and perinatal risks]

OBJECTIVES

The proportion of women with advanced age at the time of delivery increases constantly, partly due to assisted reproductive technologies. Maternal morbidity is known to increase with maternal age, whereas data on perinatal outcomes are controversial. Risks of maternal and perinatal complications may be elevated among older pregnant women. The purpose of this study is to quantify these risks among 43 years or older women in comparison with women aged 25 to 35 years, the age known to be optimal for a pregnancy.

PATIENTS AND METHODS

A retrospective study was conducted during three years (2008-2010) in a level 3 maternity unit, comparing maternal and perinatal outcomes between women who were at least 43 years old and a control group composed of drawn lots mothers between 25 and 35 years of age at the time of delivery. Maternal and perinatal outcomes were studied using uni- and multivariate analysis. As in vitro fertilization (IVF) and twin pregnancy are associated with maternal age and several complications, we compared 43 years or older women with a control group using three categories: "43 years or older without IVF", "43 years or older with IVF and singleton" and "43 years or older with IVF and twin".

RESULTS

Three hundred and sixty one women aged at least 43 years at the time of delivery (mean age: 44.6 years) were compared with 361 women aged 25 to 35 years (mean age: 31.0 years). Cesarean and preterm delivery rates were significantly higher in the study group (43.5% vs. 21.7% and 18.4% vs. 6.5% respectively, p<0.05), with higher risks after adjustment (adjusted OR=2.3 [1.6-3.4] and 2.4 [1.3-4.3], respectively). Gestational hypertension and preeclampsia rates were significantly higher among the 43 years or older women compared with the control group (11.1% vs 3.6% and 8.3% vs. 3.1% respectively, P<0.05) but this difference was not significant in multivariate analysis. The rate of preterm delivery was four fold higher among the 43 years or older women with IVF and twin in comparison with those who have a spontaneous pregnancy (52.3% vs. 13.0%, P<0.001). Cesarean delivery rate was also significantly increased in this subgroup.

CONCLUSION

Most women having a spontaneous singleton pregnancy at 43 years or older have an uneventful pregnancy outcome. However, in comparison with the women aged 25 to 35 years, they have significantly higher risks of cesarean and preterm delivery. These risks significantly increase with IVF and twin pregnancy among older women. Women aged 43 years or older should be informed about these risks to make an enlightened decision, particularly when IVF is needed.

The oldest gravidas: a review of pregnancy risks in women over 45

As a result of delayed childbearing and increasingly sophisticated assisted reproductive technologies, pregnancy in women aged ≥45 years is becoming more common. Women in this age-group should receive thorough preconception evaluation and counseling about their specific risks in pregnancy. Although many pregnancies in women >45 years old are achieved via assisted reproductive technologies with associated preconception counseling, as many as 45% may be spontaneously conceived. It is therefore important for obstetrician-gynecologists to incorporate education for older women about the risks of pregnancy into routine office visits, and to ask women in this age-group about pregnancy planning. Additionally, many pregnancies in women aged >45 years may be safely managed in a nontertiary care center, avoiding the need for referral and transfer of care to an unfamiliar setting. This review addresses preconception evaluation and counseling, real and perceived risks in older mothers, common pregnancy complications and management of pregnancy in women >45 years old.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be better able to counsel women about the risks of pregnancy for women aged ≥45, evaluate older women for common risk factors that may further increase risk in pregnancy, assess pregnancy complications that are more common in women aged >45, and manage otherwise uncomplicated pregnancies in women in this age-group.

Pregnancies beyond the Human Biological Fecundity

The maternal age at first delivery constantly rises in developed countries due to a social trend to postpone the age of parenting. Assisted reproduction technologies do extend the age of fecundity to some limit, but their success rate is inversely related to the patients' age. The major factor limiting human fecundity in the fifth decade of life is the quality of the human oocyte. This problem can be readily bypassed using oocytes from young donors thus significantly extending the age limit in which conception and delivery are possible well into menopause. The ability to become pregnant and deliver at such an age raises serious medical, moral, social and legal concerns regarding the health and welfare of the mother, child and oocyte donor, which will be presented and discussed here.

Pregnancy outcome in late maternal age in a high-income developing country

AIM

This study aimed to compare the pregnancy outcome at maternal age 35 years and above with those aged between 20 and 34 years in a high-income developing country.

METHODS

In this prospective study, pregnant women that delivered at Al-Ain Hospital from the 1st April 2009 till 30th September 2009 were included. The obstetrical and perinatal outcome of mothers aged between 20 and 34 years and those aged 35 years old and above was compared.

RESULTS

There were a total of 888 patients. 699/888 (78.7%) were aged between 20 and 34 years and 189 (21.3%) were aged 35 years and above. Advanced maternal age was significantly associated with a higher incidence of type II diabetes mellitus (p = 0001), hypothyroidism (p = 0.02), history of miscarriages (p = 0.0001), GDM (p = 0.0001), placenta previa p = 0.04, induction of labor (p = 0.04), and Cesarean section (p = 0.009).

CONCLUSION

Pregnant women at 35 years and above have higher incidence of gestational diabetes mellitus, placenta previa, and operative delivery. However, perinatal outcome are comparable to younger mothers.