Great grand multiparity--beyond the 10th delivery

Is Grand Multiparity an Independent Risk Factor for Blood Transfusion?

The relation between grand multiparity and poor pregnancy outcome, especially postpartum hemorrhage and blood transfusion, has displayed inconsistent findings. Some studies have identified an increased maternal and neonatal morbidity, but the more recent literature is less clear about the risks. The objective of the study is to determine the association of grand multiparity with postpartum blood transfusion. We conducted a retrospective cohort study in a single tertiary university-affiliated medical center between 2011 and 2019. All women were categorized into one of three groups based on the number of previous deliveries: (a) nulliparous (no previous delivery), (b) multiparous (1-4 previous deliveries), and (c) grand multiparous (≥ 5 previous deliveries). We compared the demographic, clinical, and pregnancy outcomes of the study groups. The primary outcome was the need for red blood cell transfusion during the index admission. During the study period, there were 87,343 deliveries in our center. Among the study population, 36,777 (42.1%) were nulliparous, 49,072 (56.1%) were multipara, and 1494 (1.7%) were grand multiparous. Overall, 1602 women (1.8%) were treated with RBC transfusion. Cesarean delivery, macrosomia, preterm delivery, multiple gestations, antenatal anemia, thrombocytopenia, intrauterine fetal death (IUFD), and prolonged second or third stage of labor were more prevalent among women who were treated with RBC transfusion. After controlling for potential confounders, including maternal age, preterm delivery, IUFD, mode of delivery, and antenatal thrombocytopenia, grand multiparity was found to be an independent protective factor for RBC transfusion (RR = 0.2 (0.007-0.56). After controlling for cofounders, grand multiparity alone is not associated with postpartum blood transfusion.

Medical and obstetric comorbidities and delivery outcomes in overweight and obese parturients: a retrospective analysis

BACKGROUND

Research on obesity in women of reproductive age is heterogeneous in gestational age and body mass index (BMI) classification and focused mostly on pregnancy-related rather than medical comorbidities. We studied the prevalences of pre-pregnancy BMI, chronic maternal and obstetric comorbidities, and delivery outcomes.

METHODS

Retrospective analysis of real-time data collected during deliveries in a single tertiary medical center. Pre-pregnancy BMI was classified into seven groups (kg/m²): underweight (BMI < 18.5), normal weight 1 (18.5 ≤ BMI < 22.5), normal weight 2 (22.5 ≤ BMI < 25.0), overweight 1 (25.0 ≤ BMI < 27.5), overweight 2 (27.5 ≤ BMI < 30.0), obese (30.0 ≤ BMI < 35.0), and morbidly obese (BMI ≥ 35.0). Data were collected on maternal demographics, chronic medical and obstetric comorbidities, and delivery outcomes.

RESULTS

Included were 13,726 women aged 18-50 years, with a gestational age of 24^0/7-41^6/7 weeks. Pre-pregnancy weights were 61.4% normal, 19.8% overweight, 7.6% obese, and 3.3% morbidly obese. Smoking was more prevalent among morbidly obese than among normal weight women. Obese and morbidly obese women were older and had more diabetes mellitus, hypertension, preeclampsia/eclampsia, and prior cesarean deliveries than normal weight parturients. Obese and morbidly obese women were also less likely to have a non-spontaneous conception, enter labor spontaneously (observed in the full study population and in a subgroup of term parturients), and were more likely to undergo cesarean rather than vaginal delivery. Subgroup analysis of primiparous women yielded similar results.

CONCLUSIONS

We identified a potential association between pre-pregnancy obesity and morbid obesity and higher rates of obstetric comorbidities, less natural conception and spontaneous labor, and more cesarean deliveries and adverse delivery outcomes. It remains to be seen if these findings remain after adjustment and whether they are related to obesity, treatment, or both.

Grand multiparity and the possible risk of adverse maternal and neonatal outcomes: a dilemma to be deciphered

BACKGROUND

The relation between grand multiparity (GMP) and the possible adverse pregnancy outcomes is not well identified. GMP (parity ≥5 births) frequently occurs in the Arab nations; therefore, this study aimed to identify the correlation between GMP and the different adverse maternal and neonatal outcomes in the Saudi population.

METHOD

This cohort study was conducted on a total of 3327 women from the labour ward in King Khaled University Hospital, Riyadh, Saudi Arabia. Primiparous, multiparous and grand multiparous females were included. Socio-demographic data and pregnancy complications like gestational diabetes or hypertension, preeclampsia and intrauterine growth restriction were retrieved from the participants' files. In addition, the labour ward records were used to extract information about delivery events (e.g. spontaneous preterm delivery, caesarean section [CS]) and neonatal outcomes including anthropometric measurements, APGAR score and neonatal admission to the intensive care.

RESULTS

Primiparas responses were more frequent in comparison to multiparas and GMP (56.8% and 33%, and 10.2% respectively). In general, history of miscarriage was elevated (27.2%), and was significantly higher in GMP (58.3%, p < 0.01). Caesarean delivery was also elevated (19.5%) and was significantly high in the GMP subgroup (p < 0.01). However, after adjustment for age, GMP were less likely to deliver by CS (odds ratio: 0.6, 95% CI: 0.4-0.8; p < 0.01). The two most frequent pregnancy-associated complications were gestational diabetes and spontaneous preterm delivery (12.6% and 9.1%, respectively). The former was significantly more frequent in the GMP (p < 0.01). The main neonatal complication was low birth weight (10.7%); nevertheless, neonatal admission to ICU was significantly higher in GMP (p = 0.04), and low birth weight was more common in primiparas (p < 0.01). Furthermore, logistic regression analysis revealed an insignificant increase in the maternal or neonatal risks in GMP compared to multiparas after adjustment for age.

CONCLUSION

Grand multiparous Saudi females have similar risks of maternal and neonatal complications compared to the other parity groups. Advanced age might play a major role on pregnancy outcomes in GMP. Nevertheless, grand multiparty might not be discouraged as long as women are provided with good perinatal care.

Grand Multiparity: Risk Factors and Outcome in a Tertiary Hospital: a Comparative Study

AIM

The aim of the current study was to determine the prevalence of grand multiparity and the associated risks factors.

METHODS

Four hundred thirty grandmutliparas (parity 5 or more) were compared with multiparous population (parity 2-4) with regard to maternal age, gestational age, mode of delivery, fetal and maternal outcomes and inter-current medical and obstetrical problems.

RESULTS

There were significant association between grand multiparity and adverse pregnancy outcomes such as cesarean delivery (OR=2.699, CI=2.072-3.515, p<0.001), fetal macrosomia (OR=1.675; 95% CI=1.004- 2.796, p=.048), Diabetes mellitus (OR=1.634, 95%CI=1.076-2.481, p=0 .021), and pregnancy induced hypertension (OR=1.838, 95% CI=1.054-3.204, p= .032). No significant associations were seen in placenta abruption, placenta previa, preterm labor, postpartum hemorrhage and the frequency of admission to neonatal intensive care unit. No prenatal or maternal mortality was reported in this study.

CONCLUSION

Grand multiparty remains a major obstetrics problem. It is associated with many medical and obstetrical complications. In communities where large family is desirable it is important to address the value of family planning and conduction of meticulous antenatal care.

Grandmultiparity: risk factors and outcome in a tertiary hospital: a comparative study

AIMS

The aim of the current study was to determine the prevalence of grandmultiparity and the associated risks factors.

METHODS

Four hundred thirty grandmutliparas (parity 5 or more) were compared with multiparous population (parity 2-4) with regard to maternal age, gestational age, mode of delivery, fetal and maternal outcomes and inter-current medical and obstetrical problems.

RESULTS

There were significant association between grandmultiparity and adverse pregnancy outcomes such as cesarean delivery (OR=2.699, CI=2.072-3.515, p<0.001), fetal macrosomia (OR=1.675; 95% CI=1.004- 2.796, p=.048), Diabetes mellitus (OR=1.634, 95%CI=1.076-2.481, p=0.021), and pregnancy induced hypertension (OR=1.838, 95% CI=1.054-3.204, p=.032). No significant associations were seen in placenta abruption, placenta previa, preterm labor, postpartum hemorrhage and the frequency of admission to neonatal intensive care unit. No prenatal or maternal mortality was reported in this study.

CONCLUSION

Grandmultiparty remains a major obstetrics problem. It is associated with many medical and obstetrical complications. In communities where large family is desirable it is important to address the value of family planning and conduction of meticulous antenatal care.

Obstetric complications in grand and great grand multiparous women

OBJECTIVE

To investigate pregnancy and labour outcomes in grand and great grand multiparous women.

STUDY DESIGN

A retrospective population-based study was conducted between the years 1988 and 2007. Parturients were classified into three groups: multiparous; 2-5 deliveries, grand multiparous; 6-9 deliveries, and great grand multiparous; 10+ deliveries. Stratified analyses included multiple logistic regression models.

RESULTS

A significant linear association was found between parity and adverse maternal and perinatal outcomes such as malpresentation, labour dystocia, caesarean delivery, postpartum haemorrhage, maternal anaemia (HB<10), congenital malformations and perinatal mortality. Using multivariable logistic regression models, grand multiparity was found an independent risk factor for labour dystocia, first stage (OR=1.5, P<0.001), and perinatal mortality (OR=2.0, P<0.001). Great grand multiparity was found an independent risk factor for labour dystocia, first stage (OR=2.6, P<0.001), labour dystocia, second stage (OR=2.1, P<0.001), and perinatal mortality (OR=2.5, P<0.001).

CONCLUSION

Women with high birth order are at increased risk for adverse obstetric outcomes. The risk is higher for great grand multiparous women compared to grand multiparous women. Grand and great grand multiparity are independent risk factors for labour dystocia and perinatal mortality.

Great grand multiparity: is it a risk?

We wished to compare antenatal and intrapartum complications among women delivering for the 10th or subsequent time and to compare them with women of lower parity (para 2-5). The records of 154 women of great grand parity (para >/= 10) were reviewed and compared with 308 women (para 2-5) delivered during the same period. Antepartum as well as intrapartum complications were compared. All the women delivered between 16 April 1994 and 15 January 1995. Great grand multiparous women were, not surprisingly, older. The incidence of diabetes millitus, chronic hypertension, preterm labour are similar to those with low parity while they have higher incidence of pre-eclampsia (7.1% vs. 2.6%) and intrauterine fetal death (5.2 vs. 1.3%) P < 0.04. There were no differences in the incidence of placental abruption, placenta previa, malpresentation and postpartum haemorrhage between the two groups. Great grand multipara had a higher incidence of macrosomia (7% vs. 2%) and operative delivery (20.6% vs. 11.4%) P < 0.02. Great grand multiparous woman are at some increased risk of having severe pre-eclampsia, intrauterine fetal death macrosomia and subsequently operative delivery with its associated risk of maternal mortality and morbidity.

Is grandmultiparity an independent risk factor for adverse perinatal outcomes?

OBJECTIVE

To compare maternal and neonatal outcomes among grandmultiparous women to those of multiparous women 30 years or older.

METHODS

A database of the vast majority of maternal and newborn hospital discharge records linked to birth/death certificates was queried to obtain information on all multiparous women with a singleton delivery in the state of California from January 1, 1997 through December 31, 1998. Maternal and neonatal pregnancy outcomes of grandmultiparous women were compared to multiparous women who were 30 years or older at the time of their last birth.

RESULTS

The study population included 25,512 grandmultiparous and 265,060 multiparous women 30 years or older as controls. Grandmultiparous women were predominantly Hispanic (56%). After controlling for potential confounding factors, grandmultiparous women were at significantly higher risk for abruptio placentae (odds ratio OR: 1.3; 95% confidence intervals CI: 1.2-1.5), preterm delivery (OR: 1.3; 95% CI: 1.2-1.4), fetal macrosomia (OR: 1.5; 95% CI: 1.4-1.6), neonatal death (OR: 1.5; 95% CI: 1.3-1.8), postpartum hemorrhage (OR: 1.2; 95% CI: 1.1-1.3) and blood transfusion (OR: 1.5; 95% CI: 1.3-1.8).

CONCLUSION

Grandmultiparous women had increased maternal and neonatal morbidity, and neonatal mortality even after controlling for confounders, suggesting a need for closer observation than regular multiparous patients during labor and delivery.

Effect of grand multiparity on intrapartum and newborn complications in young women

OBJECTIVE

To examine the effect of high parity on complications in young women, aged 18-34 years.

METHODS

Seven years of Utah birth certificate data were reviewed (1995-2001). Young nulliparas and primiparas were compared with young grand and great grand multi-paras by using logistic regression. Young grand multiparas were compared with older grand multiparas.

RESULTS

Young grand multiparas were more likely to have a preterm delivery and less likely to experience fetal distress, instrumented delivery, cesarean delivery, and any intrapartum complication than young nulliparas or primiparas. Young grand multiparas were less likely to experience many complications than their older counterparts.

CONCLUSION

Among young women, grand and great grand multiparity does not increase the risk for most intrapartum and newborn complications. Young grand and great grand multiparas are at significantly decreased risk for many complications when compared with young women of lower parity and older grand and great grand multiparas.

LEVEL OF EVIDENCE

II-2.

Induction of labor in great grandmultipara with misoprostol

OBJECTIVE

To compare the efficacy and complications of intravaginal misoprostol application with oxytocin infusion for induction of labor in great grandmultiparous pregnancies with a Bishop score of <6.

STUDY DESIGN

Sixty-four great grandmultiparous (delivering the tenth, or greater, infant) pregnant patients with a Bishop score of <6 were randomized in two groups with 32 patients receiving 50 microg intravaginal misoprostol four times with 4h intervals, and 32 patients receiving oxytocin infusion for induction of labor starting from 2 mIU/min, increasing it every 30 min with 2 mIU/min increments up to maximum of 40 mIU/min. The time from induction to delivery, the route of delivery, fetal outcome and maternal complications were recorded. Statistical analyses were performed using Mann-Whitney U-test, Chi-Square test and hypothesis test about differences for two proportions (t-test) to determine differences between the two groups. P < or = 0.05 was considered significant.

RESULT

The mean time from induction to delivery was 9.91+/-4.30 and 10.88+/-4.72 h in the misoprostol and oxytocin administered group, respectively, with no significant difference between the groups. The rate of vaginal delivery was 84.4 and 87.5% in the misoprostol and oxytocin administered group, respectively, with no significant difference between the groups (P = 0.72). The rates of placental abruption and postpartum hemorrhage were similar in both groups and no case of uterine rupture occurred. The 1 and 5 min mean Apgar scores were 6.91+/-1.57-8.88+/-1.39 and 7.22+/-1.24-9.06+/-0.84 in the misoprostol and oxytocin administered group with no significant differences between the groups (P = 0.38 and 0.51). No case of asphyxia was present. The rate of admission to neonatal intensive care unit was higher in the misoprostol administered group, but the difference was not significant.

CONCLUSION

Intravaginal misoprostol is an alternative method to oxytocin in induction of labor in great grandmultiparous pregnant women with low Bishop scores, as it is effective, cheap and easy to use. Safety about rare complications and neonatal morbidity needs clarifications with further studies.

High Parity and Fetal Morbidity Outcomes

OBJECTIVE

We investigated the association between high parity and fetal morbidity outcomes.

METHODS

We analyzed 22,463,141 singleton deliveries at 20 weeks or more of gestation in the United States from 1989 through 2000. Adjusted odds ratios generated from logistic regression models were used to approximate relative risk for neonatal morbidity in women with 1-4 (moderate parity or type I; referent group), 5-9 (high parity or type II), 10-14 (very high parity or type III) and 15 or more (extremely high parity or type IV) prior live births. Main outcome measures included low and very low birth weight, preterm and very preterm birth, and small and large for gestational age delivery.

RESULTS

The overall crude rates for low birth weight, very low birth weight, preterm birth, very preterm birth, and small and large for gestational age were 55, 11, 97, 19, 83, and 129 per 1,000 live births, respectively. The adjusted odds ratios for low birth weight, very low birth weight, preterm, and very preterm delivery increased consistently and in a dose-effect fashion with ascending parity (P for trend < .001). In the case of large for gestational age delivery, the adjusted odds ratio showed an inverted-U pattern, being highest among women in the type III parity cluster. The findings with respect to small for gestational age were inconclusive.

CONCLUSION

High parity is a risk factor for adverse fetal outcomes. However, the impact of heightened parity is more manifest as shortened gestation rather than physical size restriction. These findings could prove beneficial for counseling women of high parity.

High parity and adverse birth outcomes: exploring the maze

BACKGROUND

Despite extensive literature on the topic, it is uncertain if grand (para > or = 5) and great grand (para > or = 10) multiparity are associated with adverse birth outcomes. We critically evaluate the evidence for and against the existence of adverse maternal and/or fetal outcomes in high parity women.

METHODS

An electronic search of MEDLINE and other bibliographic databases (Current Contents, EMBASE, and CAB) was conducted, and all relevant articles in English language were retrieved.

RESULTS

Findings on the association between high parity and maternal-fetal birth outcomes are not consistent. Although the older literature tends to suggest that multiparity is a risk factor for negative birth outcomes, more recent reports are not supportive. Comparison across studies was further complicated by confounding factors like maternal age, socioeconomic status, and levels of prenatal care, as well as by variations in study designs and in the definition of parity itself. Furthermore, most studies that examined women of extreme parity (para > or = 10) were handicapped by inadequate power.

CONCLUSIONS

After accounting for quality, culture, and degrees of associations, the preponderance of evidence seems to point to possible existence of heightened risk for certain medical complications and placental pathologies among women of extreme parity. The literature also provides reasonable evidence for a higher-than-expected likelihood for occurrence of fetal macrosomia with advanced parity.

Extreme grandmultiparity: is it an obstetric risk factor?

OBJECTIVE

To examine the perinatal outcome in women of extreme grandmultiparity (EGMP) in a setting with good socio-economic conditions and modern perinatal care.

METHODS

About 1015 pregnant women with a parity of 10 and above who delivered at Al-Mafraq hospital, Abu Dhabi between 1992 and 1998 were compared with 2044 women of parity <5 and 1662 with parity of 5-9.

RESULTS

Pregnant women with parity of 10 and above had an increased incidence of gestational diabetes (P<0.001) and macrosomia (P<0.001) and a reduced incidence of preterm delivery (P<0.0001) and induction of labor (P<0.0001). There were no significant differences between the groups regarding, antepartum hemorrhage, cesarean section rate and neonatal outcomes.

CONCLUSION

Extreme grandmultiparity does not appear to be an independent risk factor for adverse perinatal outcome in the setting of good perinatal care.

Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors

OBJECTIVE

We sought to compare obstetric and neonatal complications among great-grand multiparous, grand multiparous, and multiparous women.

STUDY DESIGN

One hundred thirty-three great-grand multiparas, 314 grand multiparas, and 2195 multiparas who were delivered of their infants between 1988 and 1998 were selected for the study. To facilitate comparison, the patients were all >35 years old and had similar socioeconomic characteristics.

RESULTS

The incidence of malpresentation at the time of delivery, maternal obesity, anemia, preterm delivery, and meconium-stained amniotic fluid increased with higher parity, whereas the rate of excessive weight gain and cesarean delivery decreased. Compared with grand multiparas, great-grand multiparas had significantly elevated risks for abnormal amounts of amniotic fluid, abruptio placentae, neonatal tachypnea, and malformations but lower rates of placenta previa (P <.05). The incidence of postpartum hemorrhage, preeclampsia, placenta previa, macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand multiparas than in multiparas, whereas the proportion of induction, forceps delivery, and total labor complications was significantly lower than in the multiparous group (P <.05). Similar frequency of maternal diabetes, infection, uterine wall scar rupture, variations in fetal heart rate, fetal death, and neonatal mortality was found in the 3 groups.

CONCLUSION

Both high-parity groups have their own risk factors, but the rate of some complications decreases with higher parity. In addition, perinatal mortality remains low in these patients, and therefore, under satisfactory socioeconomic and health care conditions, high parity should not be considered dangerous.

Peripartum complications in grand multiparous women: para 6-9 versus para > or =10

OBJECTIVE

To assess the importance of birth order and advanced maternal age on maternal and peripartum complications.

STUDY DESIGN

The study population consisted of 12 296 multiparous women (six deliveries or more) with singleton gestation. Patients were classified into two groups according to the birth order: grand multiparous (between six and nine deliveries) and huge multiparous (ten or more deliveries). Peripartum complication was defined when at least one of the following conditions occurred: massive hemorrhage, uterine rupture, abruptio placentae, dysfunctional labor or malpresentations. Logistic regression analysis was used to evaluate the relationship between birth order and maternal age and peripartum complications.

RESULTS

Among the study population, 9587 (78%) were grand multiparous and the remaining 2709 were huge multiparous women. The rate of peripartum complications was higher in huge multiparous than in grand multiparous women: malpresentation (6.2% versus 5%, P<.005), massive hemorrhage (0.7% versus 0.4%, P<.001) and dysfunctional labor (6.4% versus 3.5%, P<.001). Huge multiparous women also had a higher rate of the following complications than grand multiparous women: cesarean section (14.4% versus 10.4%, P<.01), chronic hypertension (7.9% versus 3%, P<.001), severe pregnancy induced hypertension (2.6% versus 1.1%, P<.01), diabetes class A (10.7% versus 7.5%, P<.005), diabetes class B-R (4.3% versus 2%, P<.01) congenital anomalies (3.3% versus 2.6%, P<.05) and large for gestational age infant, (17% versus 12.4%, P<.01). When adjusted for maternal age, high birth order remained strongly associated with the occurrence of peripartum complications.

CONCLUSIONS

Huge multiparity was associated with a higher rate of maternal and peripartum complications than grand multiparity. Higher birth order remained an independent risk factor for peripartum complications after adjustment for maternal age.

Great grand multiparity: is it a risk?

OBJECTIVE

To compare antenatal and intrapartum complications incidence among women delivering for the 10th time or more and to compare this with those of low parity (para 2-5).

METHODS

The records of (154) women of great grand multipara (para > 10) were reviewed and compared with (308) women (para 2-5) delivered during the same period. Antepartum as well as intrapartum complications were compared, all occurring between 16 April 1994 and 15 January 1995.

RESULTS

Great grand multiparous women are older. The incidence of diabetes mellitus, chronic hypertension and preterm labor are similar to those with low parity, while they have higher incidences of pre-eclampsia (7.1% vs. 2.69%) and intrauterine fetal death (5.2 vs. 1.3%) P < 0.025. There were no differences in the incidences of placental abruption, placenta previa, malpresentation, postpartum hemorrhage and operative delivery between the two groups. Great grand multipara also have a higher incidence of macrosomia (12% vs. 12%) P < 0.0001.

CONCLUSION

Great grand multiparous woman are at increased risk of having pre-eclampsia, intrauterine fetal death and macrosomia.