Outcomes of Women Delivering at Very Advanced Maternal Age

Postmenopausal Pregnancy Via Oocyte Donor and Suspected Focal Placenta Accreta: A Case Report

Advances in assisted reproductive technologies have enabled postmenopausal women to achieve pregnancy beyond their reproductive lifespan. Although rare, these pregnancies are challenging and require a multidisciplinary approach due to the higher prevalence of medical comorbidities in this population. The placenta accreta spectrum is characterized by an abnormal invasion of chorionic villi into the myometrium. Risk factors associated with the placenta accreta spectrum include prior uterine surgeries, advanced maternal age, multiparity, in vitro fertilization, and placenta previa. We present a case of a 59-year-old postmenopausal woman with chronic hypertension, stage II chronic kidney injury, and superimposed pre-eclampsia who underwent cesarean delivery complicated by suspected focal placenta accreta. Histopathological examination revealed significant deviations from normative placental architecture, emphasizing the invasion of the villi. Further, congested blood vessels and the presence of inflammatory cells, along with heightened collagen deposition, suggest an underlying pathological process affecting placental health. These findings underscore a perturbation of placental homeostasis, emphasizing the necessity for further investigation into the mechanisms contributing to placental pathology in postmenopausal pregnancies.

Association between very advanced maternal age women with gestational diabetes mellitus and the risks of adverse infant outcomes: a cohort study from the NVSS 2014-2019

BACKGROUND

To evaluate the association between gestational diabetes mellitus (GDM) and infant outcomes in women of very advanced maternal age (vAMA) (≥45 years).

METHODS

This cohort study utilized data from the National Vital Statistics System (NVSS) database (2014-2019) in the United States. Preterm birth was the primary outcome, which was subdivided into extremely preterm, very preterm, and moderate or late preterm. The secondary outcomes were neonatal intensive care unit (NICU) admission, low birthweight and small for gestational age. Univariate and multivariate logistic regression analyses were used to explore the association between GDM and infant outcomes among vAMA women. Subgroup analyses were performed based on race and use of infertility treatment. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated.

RESULTS

A total of 52,544 vAMA pregnant women were included. All analysis made comparisons between women with vAMA and GDM and women with vAMA and no GDM. Women with GDM had a significantly higher risk of preterm birth than those without GDM (OR = 1.26, 95%CI = 1.18-1.36, P < 0.001). Compared with women without GDM, those with GDM had a significantly increased risk of moderate or late preterm birth (OR = 1.27, 95%CI = 1.18-1.37, P < 0.001); no significant association of GDM with extremely preterm birth and very preterm birth was observed. Women with GDM had a significantly greater risk of NICU admission than those without (OR = 1.33, 95%CI = 1.23-1.43, P < 0.001). GDM was associated with a significantly lower risk of low birthweight (OR = 0.91, 95%CI = 0.84-0.98, P = 0.010), and no significant association was found between GDM and small for gestational age (OR = 0.95, 95%CI = 0.87-1.03, P = 0.200) in vAMA women.

CONCLUSION

vAMA women with GDM had an increased risk of preterm birth, especially moderate or late preterm birth. NICU admission and low birthweight were also associated with GDM among vAMA women.

Obstetric Care Consensus #11, Pregnancy at age 35 years or older

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those found in younger pregnant populations, even in healthy individuals with no other comorbidities. There are several studies that suggest that advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetrical care with anticipated delivery at the age of 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

Age-specific effects on adverse pregnancy outcomes vary by maternal characteristics: a population-based retrospective study in Xiamen, China

BACKGROUND

Advanced maternal age (AMA; ≥35 years) is considered to be a major risk factor for adverse pregnancy outcomes. Along with the global trend of delayed childbearing, and in particular, the implementation of China's second and third-child policy leading to a dramatic increase of AMA in recent years, the association between maternal age and pregnancy outcomes requires more investigation.

METHODS

A population-based retrospective study was performed. Data were derived from the Medical Birth Registry of Xiamen from 2011 to 2018. Univariate and multivariate logistic regression was used to evaluate the effects of maternal age on pregnancy outcomes.

RESULTS

A total of 63,137 women categorized into different age groups (< 25 years, 25-29 years, 30-34 years, and ≥ 35 years) were included in this study. Compared with the mothers aged 25-29 years, the univariate regression analysis showed that mothers aged < 25 years had lower risks of gestational diabetes mellitus (GDM) and cesarean. AMA was associated with higher risks of GDM, hypertension, cesarean, preterm birth, low-birth weight (LBW), large-for-gestational-age (LGA), macrosomia, and stillbirth (all P < 0.01). After adjustment for potential confounding factors, increased risks of GDM, hypertension, cesarean, preterm birth, and LBW remained significantly associated with AMA (all P < 0.05), whereas AMA mothers showed a lower risk of macrosomia than their younger counterparts. Additionally, no significant differences were detected in terms of Apgar score < 7.

CONCLUSION

AMA was associated with adverse pregnancy outcomes including increased risks of GDM, hypertension, cesarean, preterm birth, and LBW. This study confirmed the relationship between AMA and certain adverse maternal and fetal outcomes and emphasizes the necessity for women to be cautious about the age at which they become pregnant.

Pregnancy outcomes at maternal age over 45 years: a systematic review and meta-analysis

OBJECTIVE

This study aimed to identify trends in pregnancy outcomes, especially delivery mode, among pregnant patients older than 45 years.

DATA SOURCES

A literature search was performed using PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for studies published between January 1, 2010, and June 30, 2022.

STUDY ELIGIBILITY CRITERIA

The primary outcomes were cesarean delivery and assisted delivery. The secondary outcomes were preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth. The inclusion criteria were studies examining the relationship between older age pregnancy and pregnancy outcomes, studies that compared pregnancy outcomes at maternal age ≥45 years and <45 years, and at least one of the primary and secondary pregnancy outcomes were included.

METHODS

Study screening was performed after duplicates were identified and removed. The quality of each study and publication bias were assessed. Forest plots and I² statistics were calculated for each study outcome for each group. The main analysis was a random-effects analysis. The inverse variance method was used to integrate the results if studies had an adjusted analysis.

RESULTS

Among 4209 studies initially retrieved, 24 were included in this review. All studies were retrospective, observational studies. Pregnant patients aged ≥45 years had a significantly higher cesarean delivery rate (odds ratio, 2.87; 95% confidence interval, 2.50-3.30; I²=97%) than those aged <45 years. However, the emergency cesarean delivery rate was lower in older pregnant patients (odds ratio, 0.61; 95% confidence interval, 0.47-0.79; I²=79%). Pregnancy in older individuals was associated with a lower assisted delivery rate than pregnancy in younger individuals (odds ratio, 0.85; 95% confidence interval, 0.75-0.97; I²=48%). Preeclampsia, gestational diabetes mellitus, placenta previa, placental abruption, postpartum hemorrhage, and preterm birth were more likely to occur in pregnant patients aged ≥45 years than in those aged <45 years. Adjusted pooled analyses showed trends similar to those in the unadjusted pooled analyses.

CONCLUSION

Adverse pregnancy outcomes, typically cesarean delivery, were more likely to occur in older (≥45 years) pregnant patients than in younger pregnant patients. However, the assisted delivery rate was lower in older pregnant patients.

Role of Parity and Age in Cesarean Section Rate among Women: A Retrospective Cohort Study in Hail, Saudi Arabia

In the context of the global increase in the rate of cesarean deliveries, with an associated higher morbidity and mortality, this study aimed to investigate the role of maternal age and parity in the cesarean section rate among women in the Hail Region of Saudi Arabia. This retrospective cohort study used data collected from the labor ward of the Maternity and Child Health Hospital, Hail, over a period of 8 months, forming a cohort of 500 women. Women were categorized into four different parity classes. The results revealed that there was no significant relationship between cesarean deliveries and maternal age (p-value, 0.07). There was no significant difference in the mode of delivery between the study's parity cohort group. A significant increase in cesarean deliveries was noticed among obese women with a BMI between 35-39.9 (52.14%). This increase was even greater among those with a BMI above 40 (63.83%). Fetal distress, malpresentation and abruptio placenta were the most significant indications for CS among all age groups (p-value 0.000, 0.021, and 0.048, respectively). Conclusions: The number of cesarean deliveries has no association with parity or age. However, there was a statistically significant association with BMI, a perineal tear after previous vaginal delivery, and a history of diabetes mellitus and gestational diabetes. The most reported reasons for CS were fetal distress, malpresentation, and abruptio placenta among all age groups.

Advancing understanding of maternal age: correlating epigenetic clocks in blood and myometrium

Background:

Advanced maternal age is currently a term defined by chronological age. However, a group of biomarkers known as epigenetic clocks, which can predict morbidity and mortality, has been used to estimate measures of biological aging. Uterine myometrial function during the process of parturition may be influenced by aging, as labor dystocia, unplanned intrapartum cesarean birth, and postpartum hemorrhage are more common in older individuals. The purpose of this study was to evaluate the use of epigenetic clocks in maternal myometrium and blood for predicting age and to evaluate the correlation of epigenetic age between the tissues.

Results:

We compared epigenetic age in blood and myometrial samples provided by women undergoing planned cesarean birth at term gestation. Chronological age ranged from 20 to 50 with a median (IQR) age of 35.5(8) years. The MethylationEPIC BeadChip was used to obtain DNA methylation data, and then epigenetic age was calculated using the Horvath, Hannum, GrimAge, and PhenoAge clocks. Spearman correlations of epigenetic age with chronological age were calculated. We tested the relationship of epigenetic age in maternal blood to epigenetic age in myometrium. Age acceleration, for each clock, was also correlated between tissues. Twenty-seven participants provided samples, and 21 matched specimens were included in the final analysis after quality control. Spearman correlation between maternal chronological age and epigenetic age were significant in three of the four clocks (pan-tissue Horvath, Hannum, and GrimAge), for both myometrium and blood samples. Correlations between blood epigenetic age and maternal age ranged from 0.72 to 0.87 (all p < 0.001). Correlations between myometrial epigenetic age and maternal age were also significant (0.62–0.70, p = 0.002), though lower than correlations seen in blood. Maternal blood epigenetic age also correlated with epigenetic age in myometrium with each of these three clocks 0.60 (p = 0.004, Horvath), 0.63 (p = 0.003, Hannum), and 0.80 (p < 0.001, GrimAge). GrimAge age acceleration had the highest correlation between tissues among the clocks (0.49, p = 0.02).

Conclusions:

Given the limited sample, this study provides insight into the potential use of epigenetic age derived from blood as a proxy for myometrial epigenetic age, which may be a useful biomarker in estimating myometrial biological age in relationship to myometrial dysfunction. GrimAge outperformed the other tested clocks in terms of concordance of epigenetic age and age acceleration between tissues; however, the Horvath and Hannum clocks may be useful depending on the outcome of interest in pregnancy.

The effect of advanced maternal age on perinatal outcomes in nulliparous pregnancies

OBJECTIVES

In the current study, we aimed to evaluate the effect of advanced maternal age on perinatal outcomes in nulliparous singleton pregnancy.

METHODS

The perinatal outcome data of 11,366 patients who gave birth between 2015 and 2020 were evaluated retrospectively. Patients were subgrouped according to their age as control group (C) (20-29 years), late advanced maternal age group (30-34 years), advanced maternal age group (35-39 years), and very advanced maternal age group (≥40 years). Multinomial logistic regression analyses were performed to test the possible independent role of maternal age as a risk factor for adverse pregnancy outcomes.

RESULTS

Statistically significant difference was observed between the control group and the other groups in terms of preterm delivery, preeclampsia, gestational diabetes mellitus (GDM), small gestational age (SGA), large gestational age (LGA), premature rupture of membranes (PROM), high birth weight (HBW), and perinatal mortality rates (p<0.05). An increased risk of the need for neonatal intensive care unit (NICU) and perinatal mortality was observed in groups over 35 years old.

CONCLUSIONS

Age poses a risk in terms of preterm delivery, preeclampsia, LGA, GDM, and HBW in the groups over 30 years of maternal age. The rates of PROM, NICU, and perinatal mortality increase in addition to those perinatal results in the groups above 35 years of maternal age.

A machine learning approach for predicting suicidal ideation in post stroke patients

Currently, the identification of stroke patients with an increased suicide risk is mainly based on self‐report questionnaires, and this method suffers from a lack of objectivity. This study developed and validated a suicide ideation (SI) prediction model using clinical data and identified SI predictors. Significant variables were selected through traditional statistical analysis based on retrospective data of 385 stroke patients; the data were collected from October 2012 to March 2014. The data were then applied to three boosting models (Xgboost, CatBoost, and LGBM) to identify the comparative and best performing models. Demographic variables that showed significant differences between the two groups were age, onset, type, socioeconomic, and education level. Additionally, functional variables also showed a significant difference with regard to ADL and emotion (p < 0.05). The CatBoost model (0.900) showed higher performance than the other two models; and depression, anxiety, self-efficacy, and rehabilitation motivation were found to have high importance. Negative emotions such as depression and anxiety showed a positive relationship with SI and rehabilitation motivation and self-efficacy displayed an inverse relationship with SI. Machine learning-based SI models could augment SI prevention by helping rehabilitation and medical professionals identify high-risk stroke patients in need of SI prevention intervention.

Effect of advanced parental age on pregnancy outcome and offspring health

PURPOSE

Fertility at advanced age has become increasingly common, but the aging of parents may adversely affect the maturation of gametes and the development of embryos, and therefore the effects of aging are likely to be transmitted to the next generation. This article reviewed the studies in this field in recent years.

METHODS

We searched the relevant literature in recent years with the keywords of "advanced maternal/paternal age" combined with "adverse pregnancy outcome" or "birth defect" in the PubMed database and classified the effects of parental advanced age on pregnancy outcomes and birth defects. Related studies on the effect of advanced age on birth defects were classified as chromosomal abnormalities, neurological and psychiatric disorders, and other systemic diseases. The effect of assisted reproduction technology (ART) on fertility in advanced age was also discussed.

RESULTS

Differences in the definition of the range of advanced age and other confounding factors among studies were excluded, most studies believed that advanced parental age would affect pregnancy outcomes and birth defects in offspring.

CONCLUSION

To some extent, advanced parental age caused adverse pregnancy outcomes and birth defects. The occurrence of these results was related to the molecular genetic changes caused by aging, such as gene mutations, epigenetic variations, etc. Any etiology of adverse pregnancy outcomes and birth defects related to aging might be more than one. The detrimental effect of advanced age can be corrected to some extent by ART.

Pregnancy at Age 35 Years or Older: ACOG Obstetric Care Consensus No. 11

SUMMARY

Centers for Disease Control and Prevention data from 2020 demonstrate the continued upward trend in the mean age of pregnant individuals in the United States. Observational studies demonstrate that pregnancy in older individuals is associated with increased risks of adverse pregnancy outcomes-for both the pregnant patient and the fetus-that might differ from those in a younger pregnant population, even in healthy individuals with no other comorbidities. There are several studies that suggest advancing age at the time of pregnancy is associated with greater disparities in severe maternal morbidity and mortality. This document seeks to provide evidence-based clinical recommendations for minimizing adverse outcomes associated with pregnancy with anticipated delivery at an advanced maternal age. The importance and benefits of accessible health care from prepregnancy through postpartum care for all pregnant individuals cannot be overstated. However, this document focuses on and addresses the unique differences in pregnancy-related care for women and all those seeking obstetric care with anticipated delivery at age 35 years or older within the framework of routine pregnancy care. This Obstetric Care Consensus document was developed using an a priori protocol in conjunction with the authors listed above.

Distribution of Vaginal and Gut Microbiome in Advanced Maternal Age

The distribution of the microbiome in women with advanced maternal age (AMA) is poorly understood. To gain insight into this, the vaginal and gut microbiota of 62 women were sampled and sequenced using the 16S rRNA technique. These women were divided into three groups, namely, the AMA (age ≥ 35 years, n = 13) group, the non-advanced maternal age (NMA) (age &lt; 35 years, n = 38) group, and the control group (non-pregnant healthy women, age &gt;35 years, n = 11). We found that the alpha diversity of vaginal microbiota in the AMA group significantly increased. However, the beta diversity significantly decreased in the AMA group compared with the control group. There was no significant difference in the diversity of gut microbiota among the three groups. The distributions of microbiota were significantly different among AMA, NMA, and control groups. In vaginal microbiota, the abundance of Lactobacillus was higher in the pregnant groups. Bifidobacterium was significantly enriched in the AMA group. In gut microbiota, Prevotella bivia was significantly enriched in the AMA group. Vaginal and gut microbiota in women with AMA were noticeably different from the NMA and non-pregnant women, and this phenomenon is probably related to the increased risk of complications in women with AMA.

Intergenerational health effects of Medicaid

This paper investigates the effects of the introduction of Medicaid during the 1960s on next generations' birth outcomes. A federal mandate that all states must widen the coverage to all cash welfare recipients generated cross-state variations in Medicaid eligibility, specifically among nonwhites who largely overrepresented the target population. I implement a reduced-form difference-in-differences strategy that compares the birth outcomes of mothers born in states with higher cash welfare recipiency versus low welfare recipiency and different years relative to the Medicaid implementation year. Using Natality data (1970-2004), I find that Medicaid significantly improves birth outcomes. The effects are considerably larger among nonwhites, specifically blacks. The effects do not appear to be driven by preexisting trends in birth outcomes, preexisting trends in households' socioeconomic characteristics, changes in other welfare expenditures, and selective fertility. A back-of-an-envelope calculation points to a minimum of 3.9% social externality of Medicaid through income rises due to next generations' improvements in birth outcomes.

Analysis of the causes and influencing factors of fetal loss in advanced maternal age: a nested case-control study

BACKGROUND

The risk of fetal loss is higher among ≥35-year-olds than younger women. The present study aimed to explore the causes and factors influencing fetal loss in advanced maternal age (AMA).

METHODS

AMA women with singleton fetuses (< 14 gestational weeks) who underwent their first prenatal examination in the Obstetrics Department of Fujian Maternity and Child Health Hospital from December 2018 to June 2020 were included in this cohort study. Those who terminated the pregnancy before 14 gestational weeks were excluded. A baseline survey was conducted, and follow-up was carried out until the termination of the pregnancy. Clinical data were extracted to analyse the causes of fetal loss among them. In the nested case-control study, the AMA women with fetal loss were enrolled as the case group, and women without fetal loss in the same period were enrolled as the control group, in a 1:2 ratio matched by age and gestational weeks. Logistic regression models were used to analyse the factors influencing fetal loss.

RESULTS

A total of 239 women with fetal loss and 478 controls were enrolled. The causes of fetal loss were most often fetal factors, followed by maternal factors, umbilical cord factors, and placental factors. Multivariate logistic regression analysis indicated that junior high school education and below (adjusted odds ratio (aOR) = 5.13, 95% confidence interval (CI): 2.19-12.02), senior high school education (aOR = 4.91, 95% CI: 2.09-11.54), residence in a rural area (aOR = 2.85, 95% CI: 1.92-4.25), unemployment (aOR = 1.81, 95% CI: 1.20-2.71), spontaneous abortion history (aOR = 1.88, 95% CI: 1.26-2.80), preterm birth history (aOR = 11.08, 95% CI: 2.90-42.26), hypertensive disorders of pregnancy (aOR = 7.20, 95% CI: 2.24-23.12), and preterm premature rupture of membranes (aOR = 4.12, 95% CI: 1.53-11.11) were risk factors for fetal loss.

CONCLUSIONS

Low educational level, unemployment, abnormal pregnancy/labor history, and pregnancy complications were correlated with the incidence of fetal loss in AMA. Thus, early identification as well as a targeted intervention, should be conducted.

Maternal Psychological Factors and Onset of Functional Gastrointestinal Disorders in Offspring: A Prospective Study

BACKGROUND/OBJECTIVES

Functional gastrointestinal disorders (FGIDs) are a heterogeneous group of conditions of unclear etiology. The biopsychosocial model approach to FGIDs posits that early-life stressors may trigger a cascade of complex interactions between genetic predisposition and risk factors eventually leading to the occurrence of FGIDs. The relationship between the psychological disposition of the mother and FGIDs occurrence is poorly understood. We conducted a study to investigate if parental psychological factors may contribute to the onset of FGIDs in offspring.

METHODS

We performed a prospective cohort study of parent-infant pairs who completed a battery of self-reported psychological questionnaires and a validated Rome III questionnaire for the diagnosis of infant and toddler FGIDs. The Edinburgh Postpartum Depression Scale (EPDS) was used to examine postpartum depression (PPD) symptoms; the Maternity Blues Questionnaire (MBQ) was applied to measure maternity blues severity; the Symptoms Checklist-Revised (SCL90-R) was used to assess the presence of relevant psychiatric symptoms; adult attachment style in mothers was assessed in a continuous way through the five dimensions of the Attachment Style Questionnaire (ASQ).

RESULTS

Out of the 360 eligible mothers, 200 were enrolled, 113 completed the 3-month follow-up and were included in the final analysis. PPD symptoms prevalence was 20.4%, 20%, 13.2%, and 13.1% respectively at 3 days, 1 week, 1 month, and 3 months after delivery. 40.4% of mothers suffered from severe blues according to the MBQ. Relevant psychiatric symptoms (SCL90-R) were present in 7.8% and 10.9% of mothers, respectively at 1 week and 3 months after delivery. 48.7% of mothers showed a secure attachment pattern measured through the RQ. At 1-month follow-up, infant regurgitation was diagnosed in 26 (23%) of infants, infantile colic in 31 (27.4%), dyschezia in 17 (15%), and functional constipation in 9 (8%). At 3-month follow-up, FGIDs prevalence was respectively 16 (19.3%), 11 (13.3%), 4 (4.8%), and 11 (13.3%). A significant positive association between PPD symptoms starting 3 days after delivery and the presence of infantile colic on setting 1 month after birth was found (P = 0.028), as well as between PPD symptoms occurrence 7 days after delivery and infantile regurgitation beginning 1 month after birth (P = 0.042). A higher prevalence of infantile colic was found in the offspring of mothers suffering from PPD symptoms from 3 days after delivery (54.5 vs 19.8; P = 0.001). No significant association was found between FGIDs and psychiatric symptoms and maternity blues at any timepoint. On the other hand, mothers of infants with regurgitation with an onset 1 month after birth have higher insecurity score in avoidant and fearful ASQ-related attachment dimensions (respectively, P = 0.03, P = 0.042, P = 0.03).

CONCLUSIONS

Maternal psychological factors might contribute to the onset of infant FGIDs in offspring. Early screening of postpartum depression symptoms and early implementation of psychological interventions within the postpartum period might promote the health of the mother-infant dyad.

The role of parity in the mode of delivery in advanced maternal age women

Abstract Objectives: to describe the profile of Brazilian Advanced Maternal Age (AMA) women (> 35 years) according to parity, as well as to analyze the role of parity in the relationship between AMA and mode of delivery. Methods: this is a cross-sectional study, based on the “Nascer no Brasil” (Born in Brazil) survey. The data were collected in 2011/2012. The chi-square test was performed to verify the association between parity and maternal, prenatal and delivery characteristics, maternal habits, pre-pregnancy diseases, maternal complications and obstetric history. Results: of the 2,510 puerperal AMA women, 20.2% were nulliparous, 54.4% had one or two previous births and 25.4% had three or more previous births. The nulliparous women had higher schooling, higher economic class and adequate BMI, were white; and had better maternal habits when compared to multiparous. However, they were also more submitted to cesarean section, although without reported complications. Conclusions: one cannot speak of AMA pregnant women as a homogeneous group in Brazil. There are inequalities that can be revealed via parity, since nulliparous women have maternal characteristics, habits and access to prenatal care and childbirth that are more advantageous than multiparous women.

No. 394-Stillbirth Investigation

OBJECTIVES

To provide an investigation protocol to help health care providers determine the cause of a fetal death.

OPTIONS

Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries.

OUTCOMES

Identification of possible causes of stillbirth and their relationship to future pregnancies.

EVIDENCE

Articles related to the etiology of fetal death were identified in a search of PubMed (June 2006 to September 2018), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the International Stillbirth Alliance Collaborative for Improving Classification of Perinatal Deaths, the Royal College of Obstetricians and Gynaecologists, the Queensland clinical guidelines, and the Reproductive Care Program of Nova Scotia.

BENEFITS

To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies.

VALIDATION

The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care.

RECOMMENDATIONS

Risk of Selected Fetal Adverse Pregnancy Outcomes at Advanced Maternal Age: A Retrospective Cohort Study in Debre Markos Referral Hospital, Northwest Ethiopia

Introduction

Pregnancy at an advanced maternal age is defined as pregnancy at 35 years or older. Today, women postpone pregnancy due to different socioeconomic and personal reasons. However, there was limited evidence on fetal adverse outcomes' association with pregnancy at an advanced maternal age in Ethiopia and particularly in the study area. This study was aimed at assessing the effect of pregnancy at an advanced age on selected neonatal adverse pregnancy outcomes in Debre Markos Referral Hospital, Ethiopia, 2019.

Methods

Institution-based retrospective cohort study was conducted on 303 exposed (35 years and older) and 604 nonexposed (20–34 years old) immediate postpartum women who delivered at Debre Markos Referral Hospital after 28 weeks of gestation. All exposed women who fulfilled the inclusion criteria were sampled, and systematic random sampling was employed for those in the nonexposed group. The data were collected from 1st of July to 30th of December, 2019, by face-to-face interview and extraction from maternal chart using a structured questionnaire and data extraction checklist, respectively. Binary logistic regression (bivariate and multivariable) model was fitted, and wealth index was analyzed by principal component analysis. Adjusted relative risk with respect to 95% confidence interval was employed for the strength and directions of association between advanced maternal age and selected adverse pregnancy outcomes, respectively. P-value of <0.05 was used to declare statistical significance.

Results

The incidence of adverse neonatal outcomes including stillbirth, preterm birth, and low birth weight in the advanced maternal age group was 13.2%, 19.8%, and 16.5%, respectively. The incidence of stillbirth, preterm birth, and low birth weight in the nonexposed group was 3.1%, 8.4%, and 12.4%, respectively. The advanced maternal age group had three times the risk of stillbirth compared with the nonexposed group (ARR = 3.14 95% CI (1.30–7.00)). The advanced maternal age group had 2.66 times the risk of delivering preterm fetus (ARR = 2.66 95% CI (1.81–3.77)) compared with the younger counterparts. Low birth weight was not significantly associated with pregnancy at an advanced maternal age.

Conclusion

Fetal adverse outcomes including stillbirth and preterm birth were significantly associated with pregnancy at an advanced maternal age.

Placentas From Women of Advanced Maternal Age

CONTEXT.—

The percentage of pregnant women with advanced maternal age (AMA) has increased during the past several decades due to various socioeconomic factors and advances in assisted reproduction. These pregnancies are associated with adverse maternal and fetal outcomes. However, the underlying placental pathology has not been well described.

OBJECTIVE.—

To investigate the placental histopathology associated with AMA pregnancies.

DESIGN.—

Placental pathology from 168 AMA women 35 years or older at delivery was reviewed. The cases were subdivided into 2 age subgroups, ages 35 to 39 and 40 or older, as well as a "pure AMA" subgroup where the only indication for placental examination was AMA. A group of 60 consecutive non-AMA placentas was also identified and used as comparison. The spectrum of histologic features in each case was catalogued.

RESULTS.—

Of the overall AMA cases, meconium deposition was seen in 55% (93 of 168), chorangiosis in 40% (68 of 168), and acute chorioamnionitis in 36% (60 of 168). Fetal vascular malperfusion was also seen with high frequency (30%; 50 of 168). Two histologic alterations found to be significantly different between the 35 to 39 and greater than 40 age subgroups were fetal vascular malperfusion (11% [7 of 65] versus 42% [43 of 103]; P = .001) and delayed villous maturation (1.5% [1 of 65] versus 13% [13 of 103]; P = .02). The pure AMA subgroup showed no statistically significant differences compared with the overall AMA group. Chronic deciduitis was the only statistically significant difference between the overall AMA group and the non-AMA comparison group (14% [23 of 168] versus 30% [18 of 60]; P = .02).

CONCLUSIONS.—

Our findings, particularly the high frequency of fetal vascular malperfusion, suggest that AMA should be an independent indication for placental pathologic examination.

Birth and birth-related obstetrical characteristics in southwestern China associated with the current adjustment of family planning policy: a 7-year retrospective study

In China, the adjustment of the family planning policy was expected to increase the number of births and trigger a change in the demographic and obstetrical background of pregnant women. The policy itself, and corresponding background variations of the pregnant mothers, might have various influences on certain birth-related characteristics. Moreover, the adaption of the medical system to the policy needs to be demonstrated. To address these issues, over 50,000 individual records from January 2012 to December 2018 were collected from a large tertiary care centre of southwest China as a representative. The monthly numbers of deliveries and births showed stabilized patterns after remarkable upward trends. Policy-sensitive women, among whom older age and multiparity were typical features, contributed considerably to the remarkable additional births. Indeed, multivariable logistic regression analysis identified the child policy and these two background characteristics as factors influencing CS (caesarean section) rate and certain pregnancy complications or adverse outcomes. After the implementation of the two-child policy, a care provider was faced with fewer but more difficult cases. Briefly speaking, more individual-based studies on family planning policy and more efforts to improve obstetrical service are needed to better guide clinical practice in the new era.

Adverse Birth Outcomes Among Women of Advanced Maternal Age With and Without Health Conditions in Maryland

BACKGROUND

Advanced maternal age (AMA) has been linked to both higher risk of adverse birth outcomes and higher levels of comorbidities. It is unclear if adverse outcomes are higher for older healthy women. This study examined the association between AMA and adverse birth outcomes among women with and without preexisting and pregnancy-related health conditions.

METHODS

Analysis of data for 14,933 singleton births between 2004 and 2015 from the population-based Maryland Pregnancy Risk Assessment Monitoring System was conducted, comparing women aged 20-34 years and 35 years and older. Multivariable logistic regression estimated the difference in odds of preterm birth (PTB) and low birthweight (LBW) by age group among women with and without health conditions. The analysis of women without health conditions was stratified by parity.

RESULTS

Among women without health conditions, AMA was associated with higher odds of PTB regardless of birthweight, LBW regardless of term, LBW term births, and LBW PTBs; stratified analysis showed higher risk of these outcomes among both older primiparas and multiparas. Compared with younger women with hypertensive disorders, older women with similar health conditions had higher odds of PTB regardless of birthweight. Older women with asthma had higher odds of LBW term births.

CONCLUSIONS

AMA is associated with adverse birth outcomes among women with and without health conditions compared with younger women with similar health status. Improved screening and management of health conditions during pregnancy is needed for older women, regardless of parity.

Incidence and risk factors associated with postpartum depression among women of advanced maternal age from Guangzhou, China

PURPOSE

To investigate whether advanced maternal age (AMA) increases the risk of postpartum depression (PPD) at 6 weeks after birth and to explore the risk factors.

DESIGN AND METHODS

A cross-sectional study was conducted at 6 weeks postpartum. The Edinburgh Postnatal Depression Scale and a self-designed questionnaire were administered to participants. Multivariate logistic regression was used to determine risk factors.

FINDINGS

The prevalence of PPD in women of AMA was 18.0%. Poor relationships with mothers-in-law, female fetus, inconsistency between expected sex and actual sex and primiparae were identified as risk factors.

PRACTICE IMPLICATIONS

Mothers of AMA require specialized care and support to alleviate their concerns.

Cardiovascular Outcomes in Advanced Maternal Age Delivering Women. Clinical Review and Medico-Legal Issues

Background and objecives: Adverse cardiovascular outcomes during pregnancy have increased over the past few decades, with increased numbers of women delivering later in their reproductive life. Other factors include higher rates of female obesity, diabetes, hypertension, cardiovascular diseases and assisted reproductive technology, which has extended fertility. Those at risk require extensive prenatal maternal screening, constant pregnancy supervising, monitoring during labor, delivery and puerperium and careful anesthetic evaluation during delivery. Materials and Methods: The present review reports the relevant information available on cardiovascular outcomes in advanced maternal age delivering women and related medico-legal issues. The search was performed on Pubmed, Cochrane, Semantic Scholar, Medline and Embase databases, accessed by Ovid, including among others the terms "cardiomyopathy", "ischaemic heart disease", "arrhythmias", "hypertension", "peripartum period", "diabetes", "advanced maternal age" "anesthesia", "maternal morbidity and mortality" and "litigation". Results: To the extent that underestimating risk factors for peripartum cardiomyopathy (PPCM) can adversely impact maternal and fetal outcomes, the legal implications of misdiagnosis or mismanagement can result in high compensatory damages. Substantial indemnity payments drive up costs of insurance coverage. Conclusions: Multidisciplinary approaches are necessary from obstetricians, cardiologists, anesthesiologists and perinatologists for pregnancy monitoring and delivery outcomes.

Factors associated with the length of hospital stay of women undergoing cesarean section

OBJECTIVE

To evaluate whether age group, complications or comorbidities are associated with the length of hospitalization of women undergoing cesarean section.

METHODS

A cross-sectional study was carried out between June 2012 and July 2017, with 64,437 women undergoing cesarean section and who did not acquire conditions during their hospital stay. Hospital discharge data were collected from national health institutions, using the Diagnosis-Related Groups system (DRG Brasil®). The DRG referring to cesarean section with additional complications or comorbidities (DRG 765) and cesarean section without complications or associated comorbidities (DRG 766) were included in the initial diagnosis. The influence of age group and comorbidities or complications present at admission on the length of hospital stay was assessed based on the means of the analysis of variance. The size of the effect was verified by Cohen’s D, which allows evaluating clinical relevance. The criticality levels were identified using the Duncan test.

RESULTS

The longest length of hospital stay was observed in the age group from 15 to 17 years old and among those aged 45 years old or more. The hospital stay of women with complications or comorbidities at the time of admission was also longer. Moreover, it was noted that the increase in criticality level was associated with an increase in the mean length of hospital stay.

CONCLUSIONS

The length of hospital stay of women is higher among those belonging to the age group ranging from 15 to 17 years old and for those aged 45 years old or more. The presence of associated comorbidities, such as eclampsia, pre-existing hypertensive disorder with superimposed proteinuria and gestational hypertension (induced by pregnancy) with significant proteinuria increase the length of hospital stay. This study enabled the construction of distinct criticality level profiles based on the combination of age groups and the main comorbidities, which were directly related to the length of hospital stay.

Severe Maternal Morbidity in Canada: Temporal Trends and Regional Variations, 2003-2016

OBJECTIVE

This study sought to quantify temporal trends and provincial and territorial variations in severe maternal morbidity (SMM) in Canada.

METHODS

The study used data on all hospital deliveries in Canada (excluding Québec) from 2003 to 2016 to examine temporal trends and from 2012 to 2016 to study regional variations. SMM was identified using diagnosis and intervention codes. Contrasts among periods and regions were quantified using rate ratios (RRs) and 95% confidence intervals (CIs). Temporal changes were also assessed using chi-square tests for trend (Canadian Task Force Classification II-1).

RESULTS

The study population included 3 882 790 deliveries between 2003 and 2016 and 1 418 545 deliveries between 2012 and 2016. Severe hemorrhage rates increased from 44.8 in 2003 to 62.4 per 10 000 deliveries in 2012 (P for trend <0.0001) and then declined to 41.8 per 10 000 deliveries in 2016 (P for trend <0.0001). Maternal intensive care unit admission and sepsis rates decreased between 2003 and 2016, whereas rates of stroke, severe uterine rupture, hysterectomy, obstetric embolism, shock, and assisted ventilation increased. Rates of composite SMM in 2012-2016 were higher in Newfoundland and Labrador (RR 1.15; 95% CI 1.04-1.26), Nova Scotia (RR 1.11; 95% CI 1.03-1.19), New Brunswick (RR1.22; 95% CI 1.13-1.32), Manitoba (RR 1.09; 95% CI 1.03-1.15), Saskatchewan (RR 1.15; 95% CI 1.09-1.22), the Yukon (RR 1.74; 95% CI 1.35-2.25), and Nunavut (RR 1.76; 95% CI 1.46-2.11) compared with the rest of Canada, whereas rates were lower in Alberta and British Columbia.

CONCLUSION

This surveillance report helps inform clinical practice and public health policy for improving maternal health in Canada.

Programming of Vascular Dysfunction in the Intrauterine Milieu of Diabetic Pregnancies

With the rising global tide of obesity, gestational diabetes mellitus (GDM) burgeoned into one of the most common antenatal disorders worldwide. Macrosomic babies born to diabetic mothers are more likely to develop risk factors for cardiovascular disease (CVD) before they reach adulthood. Rodent studies in offspring born to hyperglycemic pregnancies show vascular dysfunction characterized by impaired nitric oxide (NO)-mediated vasodilation and increased production of contractile prostanoids by cyclooxygenase 2 (COX-2). Vascular dysfunction is a key pathogenic event in the progression of diabetes-related vascular disease, primarily attributable to glucotoxicity. Therefore, glucose-induced vascular injury may stem directly from the hyperglycemic intrauterine environment of GDM pregnancy, as evinced by studies showing endothelial activation and inflammation at birth or in childhood in offspring born to GDM mothers. This review discusses potential mechanisms by which intrauterine hyperglycemia programs dysfunction in the developing vasculature.