Advanced maternal age and its association with placenta praevia and placental abruption: a meta-analysis

Kisspeptin expression levels in patients with placenta previa: A randomized trial

BACKGROUND

This study aimed to explore the potential influence of kisspeptin (KISS1) levels on the etiology of placenta previa for early pregnancy diagnosis.

METHODS

The study included 20 pregnant women diagnosed with placenta previa and 20 pregnant woman with normal pregnancies between 2021 and 2022. Plasma KISS1 levels were determined through biochemical analysis, while genetic analysis assessed KISS1 and KISS1 receptor gene expression levels. Immunohistochemical methods were employed to determine placenta KISS1 levels.

RESULTS

The evaluation of KISS1 concentration in serum revealed a significant decrease in the placenta previa group compared to the control group (P < .001). KISS1 gene expression level 0.043-fold decreased in the placenta previa group (P < .001). Furthermore, the KISS1 receptor gene expression level increased 170-fold in the placenta previa group.

CONCLUSIONS

Results from biochemical, immunohistochemical, and genetic analyses consistently indicated significantly reduced KISS1 expression in patients with placenta previa. These findings suggest a potential link between diminished KISS1 levels and the occurrence of placenta previa. KISS1 may play a critical role in the etiology of placenta previa. Detailed studies on angiogenesis, cell migration and tissue modeling should be conducted to understand possible mechanisms.

Determinants of feto-maternal outcomes of antepartum hemorrhage among women who gave birth in Awi zone public hospitals, Ethiopia. A case-control study

BACKGROUND

Antepartum hemorrhage continues to be a major cause of maternal and perinatal morbidity and mortality in developing countries including Ethiopia and it complicates 2-5% of all pregnancies with an increased rate of maternal and perinatal morbidity and even mortality. Despite many activities, still, poor fetomaternal outcomes of antepartum hemorrhage are still there. Moreover, studies around the current study area emphasize the magnitude and associated factors for antepartum hemorrhage rather than its feto-maternal outcomes. Thus, there is a need to identify the determinants associated with the fetomaternal outcomes of antepartum hemorrhage to guide midwives and obstetricians in the early diagnosis and treatment.

METHOD

An institution-based case-control study was conducted in four-year delivery charts diagnosed with antepartum hemorrhage from April 2, 2022, to May 12, 2022, at Awi Zone public hospitals. To see the association between dependent and independent variables logistic regression model along with a 95% confidence interval (CI) and a p-value of <0.05 were used.

RESULT

No antenatal care follow-up (AOR: 2.5, 95% CI 1.49-4.2), rural residence (AOR: 1.706, 95%CI 1.09-2.66), delay to seek care >12 hours (AOR: 2.57, 95% CI: 1.57-4.23) and advanced maternal age (AOR: 3.43, 95% CI 1.784-6.59) were significant factors associated with feto-maternal outcomes of antepartum Hemorrhage.

CONCLUSION

This study revealed that rural residence, delay in seeking the care of more than 12 hours, not having antenatal care follow up and advanced maternal age were significant factors associated with feto-maternal outcomes of Antepartum hemorrhage.

RECOMMENDATION

The findings of our study suggest the need for health education about the importance of antenatal care follow-up which is the ideal entry point for health promotion and early detection of complications, especially for rural residents.

A comparative analysis of Postpartum Hemorrhage incidence and influencing factors between nulliparous and multiparous women in Hunan Province, China: A multicenter retrospective cohort study

Objectives

Postpartum hemorrhage (PPH) is a common cause of maternal death worldwide, but data on PPH incidence and influencing factors for nulliparous and multiparous women is scarce. So, the study aimed to assess the differences in PPH incidence and influencing factors between nulliparous and multiparous women.

Methods

A multicenter retrospective cohort study was conducted among women who gave birth at ≥ 28 weeks of gestation in Hunan Province, China, from January 2017 to December 2018. Logistic regression assessed PPH-influencing factors, and the receiver operating characteristic curve (ROC curve) assessed the predictive performance of identified factors.

Results

A total of 144,845 postpartum women were included in the study. The incidence of PPH (blood loss ≥ 500 ml) was 2.1 % and 1.7 % for nulliparous and multiparous women, respectively. Among the nulliparous and multiparous women, similar influencing factors of PPH included erythrocyte suspension transfusion before childbirth, anemia, soft-birth canal avulsion, Cesarean-section, placenta abruption, and general anesthesia administration before birth. Thrombophlebitis was associated [aOR 18.46(1.67-20.31)] with PPH among only the nulliparous women, while instrument-assisted birth [aOR 1.95(1.16-3.28)] and gestational hypertension [aOR 1.57(1.13-2.19)] were associated with PPH among only the multiparous women. The areas under the ROC-curve for the overall-cohort, nulliparous, and multiparous groups were [0.829(0.821-0.838)], [0.828(0.815-0.840)] and [0.833(0.822-0.844)], respectively.

Conclusion

PPH incidence is higher among nulliparous women than among multiparous women, but influencing factors vary relatively by parity. The study findings provide new insights into the use of different approaches to PPH prevention for nulliparous and multiparous women in clinical practice.

Factors and outcomes for placental anomalies: An umbrella review of systematic reviews and meta-analyses

Background

Placental anomalies, including placenta previa (PP), placenta accreta spectrum disorders (PAS), and vase previa (VP), are associated with several adverse foetal-neonatal and maternal complications. However, there is still a lack of robust evidence on the pathogenesis and adverse outcomes of the diseases. Through this umbrella review, we aimed to systematically review existing meta-analyses exploring the factors and outcomes for pregnancy women with placental anomalies.

Methods

We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception to February 2023. We used AMSTAR 2 to assess the quality of the reviews and estimated the pooled risk and 95% confidence intervals (CIs) for each meta-analysis.

Results

We included 34 meta-analyses and extracted 55 factors (27 for PP, 22 for PAS, and 6 for VP) and 16 outcomes (12 for PP, and 4 for VP) to assess their credibility. Seven factors (maternal cocaine use (for PP), uterine leiomyoma (for PP), prior abortion (spontaneous) (PP), threatened miscarriage (PP), maternal obesity (PP), maternal smoking (PAS), male foetus (PAS)) had high epidemiological evidence. Twelve factors and six outcomes had moderate epidemiological evidence. Twenty-two factors and eight outcomes showed significant association, but with weak credibility.

Conclusions

We found varying levels of evidence for placental anomalies of different factors and outcomes in this umbrella review.

Registration

PROSPERO: CRD42022300160.

Remnant cholesterol, but not other cholesterol parameters, is associated with gestational diabetes mellitus in pregnant women: a prospective cohort study

OBJECTIVE

No evidence has been found of a relationship between remnant cholesterol (RC) and the likelihood of gestational diabetes mellitus (GDM) in pregnant women. The aim of our study was to investigate the link between serum RC at 12-14 weeks of gestation and the risk of GDM.

METHODS

This was a secondary analysis with data from a prospective cohort study in Korea. A total of 590 single pregnant women attending two hospitals in Korea, up to 14 weeks gestation, from November 2014 to July 2016 were included in the study. The formula used to calculate RC in detail was RC (mg/dL) = TC (mg/dL)-HDL-c (mg/dL)-LDL-c (mg/dL). Logistic regression models were employed to examine the relationship between RC and GDM and explore the association between other lipoprotein cholesterol parameters and the risk of GDM. Furthermore, receiver operating characteristic (ROC) analysis was performed to assess the ability of RC to identify GDM. Additionally, sensitivity and subgroup analyses were conducted.

RESULTS

The mean age of participants was 32.06 ± 3.80 years. The median of RC was 34.66 mg/dL. 37 pregnant women (6.27%) were eventually diagnosed with GDM. Multivariate adjusted logistic regression analysis showed that RC was positively associated with the risk of GDM (OR = 1.458, 95% CI 1.221, 1.741). There was no significant association between other lipoprotein cholesterols (including TC, LDL-c, HDL-c) and the risk of GDM. The area under the ROC curve for RC as a predictor of GDM was 0.8038 (95% CI 0.7338-0.8738), and the optimal RC cut-off was 24.30 mg/dL. Our findings were demonstrated to be robust by performing a series of sensitivity analyses.

CONCLUSION

Serum RC levels at 12-14 weeks of gestation are positively associated with GDM risk in pregnant women. RC in early pregnancy is an early warning indicator of GDM in pregnant women, especially those with normal HDL-c, LDL-c, and TC that are easily overlooked. There is a high risk of developing GDM in pregnant women whose RC is more than 24.30 mg/dL. This study may help optimize GDM prevention in pregnant women and facilitate communication between physicians, pregnant patients, and their families.

Ultrasonographical Evaluation of Placenta Previa in Scarred and Unscarred Uterus in a Tertiary Care Centre

Objectives Placenta previa is characterised as the placenta implant in the lower uterine segment, wholly or partially covering the internal os. Uterine scars from surgical operations are a potential factor of placenta previa. The present study aims to estimate the role of ultrasound in determining the incidence of placenta previa in the scarred and unscarred uterus. Also, it aims to evaluate the types of placenta previa in the scarred and unscarred uterus. Methods This hospital-based, prospective, observational study was performed from September 2021 to August 2022 among patients referred to the Department of Radiology, Fakhruddin Ali Ahmed Medical College and Hospital (FAAMCH), Barpeta, Assam. Written informed consent was obtained from the subjects. Transabdominal and transvaginal ultrasonography methods were used to assess placenta previa. The data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY) considering a p-value < 0.05 as significant. Results Out of the 517 subjects with bleeding per vagina, 41 (7.9%) were diagnosed with placenta previa by ultrasonography. The mean maternal age was 27.80 ± 5.36 years, and the most prevalent age group was 20-24 years (31.71%). The majority (70.73%) of cases had scarred uterus. The most prevalent placental position was fundo-body anterior. Complete placenta previa was present in 26% of the total cases in the present study. Conclusion The incidence of placenta previa in the scarred uterus was higher than that of the unscarred uterus. The high prevalence of placenta previa in women with scarred uterus necessitates improved monitoring and management to avoid disastrous outcomes.

The Effect of 2016 Chinese second-child policy and different maternal age on pregnancy outcomes in Hebei Province, China

OBJECTIVE

To explore the effect of the 2016 Chinese second child policy and different maternal ages on adverse perinatal outcomes.

METHODS

Clinical data were collected from 22 monitoring hospitals in Hebei Province from January 1, 2013, to December 31, 2021. A total of 413,892 parturient were divided into 3 groups based on delivery age: 20-34, 35-39, and 40-55 years old. The clinical data were analyzed to explore the relationship among the 2016 Chinese second-child policy, maternal age, and various pregnancy risks.

RESULTS

Pregnancy complications showed an upward trend from 2013 to 2021.The top 10 incidences of pregnancy complications in Hebei Province were anemia, small for gestational age (SGA), large for gestational age (LGA), macrosomia, gestational diabetes mellitus (GDM), premature delivery, preeclampsia (PE), postpartum hemorrhage (PPH), placenta previa, and placental abruption. The two-child policy was implemented in 2016. The incidence of pregnancy complications, anemia, GDM, PE, placental abruption, cesarean delivery, premature delivery, SGA, LGA, macrosomia in 2016-2021 was significantly higher than that in 2013-2015 (P<0.05), and the proportion of women of advanced maternal age (AMA, ≥ 35 years old) increased from 2013 to 2021. Advanced maternal age was a risk factor for most assessed adverse pregnancy outcomes, including GDM, PE, placenta previa, placenta abruption, cesarean delivery, PPH, premature delivery, SGA, LGA and macrosomia.

CONCLUSION

After the adjustment of the "second-child" policy, the incidence of pregnancy complications increased. Moreover, the risk of adverse pregnancy outcomes in AMA has increased. Early prevention and intervention should be implemented to cope with the occurrence of adverse perinatal outcomes.

Desenlaces maternos según el tipo de placenta previa en un hospital de alta complejidad en Cali, Colombia. Estudio de cohorte retrospectivo

Objetivos: describir la frecuencia de complicaciones maternas en mujeres gestantes con placenta previa (PP) mayor o menor y evaluar una posible de asociación entre tipo de PP y la presencia de hemorragia materna severa y otros resultados maternos asociados. Materiales y métodos: cohorte retrospectiva, descriptiva. Se incluyeron gestantes con 20 semanas o más de embarazo, con diagnóstico confirmado de placenta previa, quienes fueron atendidas en un hospital de alto nivel de complejidad localizado en Cali (Colombia), entre enero de 2011 y diciembre de 2020. Se excluyeron las gestantes con diagnóstico de placenta previa y acretismo placentario concomitante. Las variables recolectadas fueron: edad materna, índice de masa corporal, tabaquismo, obesidad, paridad, presencia de sangrado, hemorragia posparto, manejo de la hemorragia posparto, transfusión y admisión a UCI de la gestante. Se realizó análisis descriptivo. El protocolo fue aprobado por el comité de ética de la Fundación Valle de Lili. Resultados: 146 pacientes cumplieron con los criterios de inclusión. La población estuvo constituida por mujeres con una mediana de edad de 32 años, sin antecedente quirúrgico, con diagnóstico prenatal de placenta previa a la semana 22. En el 70,5 % de los casos se trató de pacientes con placenta previa mayor. Las complicaciones más frecuentes fueron hemorragia posparto (37,9 % vs. 16,3 % para pacientes con placenta previa mayor y menor, respectivamente), requerimiento de transfusión (23,3 y 9,3 %, respectivamente) y el ingreso materno a la UCI (40,8 % vs. 18,6 %, respectivamente). No se registraron muertes maternas. Conclusiones: las mujeres con placenta previa experimentan una frecuencia elevada de complicaciones; probablemente, dicha frecuencia es más alta cuando se documenta placenta previa mayor. Se requieren más estudios que comparen la frecuencia de complicaciones maternas según el tipo de placenta previa.

Plasma Homocysteine, Folic Acid and Vitamin B12 in Abruptio Placentae: A Cross-Sectional Study of Their Role and Feto-Maternal Outcome

Background Out of the many causes of abruptio placentae, the micronutrient association with its occurrence and severity has not been researched extensively till now. We aim to measure the serum levels of homocysteine, folic acid and vitamin B12 in patients with abruptio placentae in the third trimester of pregnancy and compare the levels with those without the complication. We also propose to compare the feto-maternal outcome between the groups. Methods The cross-sectional study was undertaken in 50 pregnant women with abruption before or during delivery and 50 controls with uncomplicated pregnancy over 28 weeks of gestation. Serum levels of homocysteine, folic acid, and vitamin B12 were determined and feto-maternal outcome was compared between the groups Results Mean age of the cases and controls are 26.82 ± 5.5 and 28.82 ± 4.88 years respectively. Obstetric characteristics have significant difference between the groups in terms of gravidity, mode of delivery, timing of delivery, proportion of stillbirths and blood transfusion. The mean concentration of homocysteine and vitamin B12 between the groups also have a significant difference . The serum level of homocysteine is significantly correlated with serum vitamin B12 level (Pearson correlation= -0.601, P=0.000). However, folic acid concentration between the groups remains comparable. Conclusion Hence we conclude that vitamin B12 and homocysteine are significant determinants of abruptio placentae in pregnant women. Supplementation with the vitamin in the high-risk Indian population can avert a number of obstetric complications occurring due to raised homocysteine.

The interaction between age and parity on adverse pregnancy and neonatal outcomes

Background

Although age and parity are recognized as associated factors for adverse pregnancy outcomes, there are no studies exploring the interaction between the two during pregnancy. This study aimed to investigate the impact of the interaction between age and parity on adverse pregnancy outcomes.

Methods

This was a retrospective cohort study with 15,861 women aged ≥20 years. All women were grouped according to age, parity, and a mix of the two. The data were analyzed using multivariate logistic regression analysis.

Results

Age, parity, and interaction between the two were related with the risk of gestational hypertension, eclampsia/pre-eclampsia, placenta previa, placental implantation, postpartum hemorrhage, preterm birth, cesarean section, and Apgar score <7 within 5 min of birth. The risk of gestational diabetes mellitus and transfer to the neonatal unit was linked with age and the interaction between age and parity, but the impact of parity was not statistically significant. The risk of anemia, placental abruption, premature rupture of the membrane, oligohydramnios, and macrosomia was only associated with parity; the risk of fetal distress was only associated with age.

Conclusion

The interaction between advanced age and parity might results in more adverse outcomes for both puerpera and infants, necessitating additional prenatal screening and health education throughout pregnancy.

A Study of Clinical Characteristics, Demographic Characteristics, and Fetomaternal Outcomes in Cases of Placenta Previa: An Experience of a Tertiary Care Center

Background This study aimed to determine the demographic and clinical characteristics of pregnant women presenting with placenta previa and study the risk factors for the development of placenta previa, management strategies of associated complications, and maternal and perinatal outcomes. Methodology This prospective, observational study was conducted in the Department of Obstetrics and Gynaecology at Dr. S.N. Medical College, Umaid Hospital, Jodhpur, Rajasthan, India from May to October 2019. All patients with placenta previa were studied based on clinical presentation, management, and fetal and maternal outcomes. Results A total of 10,041 patients delivered during the study period. Of these, 61 were diagnosed with either minor placenta previa (placental edge within 2 cm, not covering the internal os) or major placenta previa (placental edge reaching or overlapping the internal os) for an incidence of 0.6%. The majority of the cases (65.57%) were in the age group of 20-29 years. Among the cases of placenta previa, 13.11% had previous cesarean sections, and 9.83% underwent previous dilatation and curettage (D & C) procedures. Moreover, 78.68% of the cases had ultrasound findings of the placenta partially or completely covering the os. Most patients were delivered by cesarean section (96.7%), and only 3.27% were delivered by vaginal delivery. Intensive care unit admission was required in 14.75% of the cases. The most common maternal complications observed were antepartum and postpartum hemorrhage, transfusion of blood and blood products, and long hospital stays. The preterm delivery rate was 62.30%, and 37.70% were term deliveries. Almost half of the babies (49.18%) were born with a birth weight of ≥2.5 kg, and 50.81% were in the low-birth-weight category. Apgar scores >7 at five minutes were observed in 85.3% of cases. Neonatal intensive care unit (NICU) admissions were 39.34%, and most babies recovered and shifted to the mother's side. The incidence of maternal mortality was 1.63%, and perinatal mortality was 9.83%. Conclusions The incidence of placenta previa was comparable to that reported in previous studies. Prevalence was more among younger women residing in rural areas who were unaware of regular antenatal check-ups. The main presenting symptom was painless vaginal bleeding, and ultrasonography was the most common diagnostic modality. Antepartum and postpartum hemorrhage was the most dreadful obstetric complications in cases of placenta previa, which affected maternal and fetal outcomes. Preterm and low birth weight were the main reason for NICU admissions. A team-based approach is required in the management of placenta previa cases.

Maternal and perinatal outcomes in women ≥40 years undergoing induction of labor compared with women <35 years: Results from 4027 mothers

AIM

Cesarean section is known to be increased with advanced maternal age in women undergoing induction of labor (IOL), but there is less information regarding other possible adverse maternal and fetal outcomes.

METHODS

Retrospective cohort study of singleton, nulliparous, at-term women undergoing IOL between January 2007 and September 2020. Outcomes studied were: cesarean section, failed induction rate, fetal distress, post-partum hemorrhage, post-partum hysterectomy, and need of transfusion. Neonatal variables analyzed were: Apgar score, umbilical cord pH, need of admission to neonatal intensive care unit, and mortality.

RESULTS

A total of 4027 women met the inclusion criteria; 1968 (48.9%) of mothers were <35 years, 1283 (31.9%) were 35-39 years, 658 (16.3%) were 40-44 years, and 118 (2.9%) were ≥45 years. Results showed a significantly increased incidence of c-section in women ≥35 years, with an OR 1.79 (95% CI 1.50-2.14) for women 40-44 years and OR 3.95 (95% CI 2.66-5.98) for women ≥45 years. The main indication for cesarean delivery was failed IOL, and this risk was also significantly increased in women ≥40 years. These differences remained significant after adjustment for confounding factors. No other adverse maternal or fetal outcomes showed an association with age.

CONCLUSION

Maternal age ≥40 years was associated with an increased risk of c-section after IOL at term compared with younger women, mainly because of failed induction, but no association with other adverse maternal or neonatal outcomes were found in our population. Risks and benefits of IOL in older women should be individually evaluated and adequately discussed with mothers.

Epidemiology, Risk Factors, and Perinatal Outcomes of Placental Abruption-Detailed Annual Data and Clinical Perspectives from Polish Tertiary Center

Placental abruption (PA) is a separation of the placenta from the uterine wall occurring with the fetus still present in the uterine cavity. It contributes to numerous neonatal and maternal complications, increasing morbidity and mortality. We conducted a retrospective study at a tertiary perinatal care center, which included 2210 cases of labor that took place in 2015 with a PA occurrence of 0.7%. No maternal or fetal death during delivery was reported in this period. The identified PA risk factors were uterine malformations, pPROM, placenta previa spectrum, and oligohydramnios. The significant maternal PA complications identified were maternal anemia, uterine rupture, and HELLP syndrome. Preterm delivery occurred significantly more often in the PA group, and the number of weeks of pregnancy and the birth weight at delivery were both significantly lower in the PA group. PA is a relatively rare perinatal complication with very serious consequences, and it still lacks effective prophylaxis and treatment. Despite its rare occurrence, each center should develop a certain strategy for dealing with this pathology or predicting which patients are at risk. Much work is still needed to ensure the proper care of the mother and the baby in this life-threatening condition.

The environmental risk factors prior to conception associated with placental abruption: an umbrella review

BACKGROUND

The present umbrella review evaluated risk factors prior to conception associated with placental abruption based on meta-analyses and systematic reviews.

METHODS

We searched PubMed, Scopus, and Web of Science until June 25, 2021. All meta-analyses that had focused on assessing the risk factors associated with placental abruption were included. We calculated summary effect estimates, 95% CI, heterogeneity I², 95% prediction interval, small-study effects, excess significance biases, and sensitive analysis. The quality of the meta-analyses was evaluated with A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2).

RESULTS

There was no risk factor in the present umbrella review with the high level of evidence (class I or II). Eight risk factors including maternal asthma (RR 1.29 95% CI 1.14, 1.47), prior cesarean section (RR 1.38, 95% CI 1.35-1.42), cocaine using (RR 4.55, 95% CI 1.78-6.50), endometriosis (OR 1.40, 95% CI 1.12-1.76), chronic hypertension (OR 3.13, 95% CI 2.04-4.80), advanced maternal age (OR 1.44, 95% CI 1.35-1.54), maternal smoking (OR 1.80, 95% CI 1.75-1.85) (RR 1.65, 95% CI 1.51-1.80), and use of assisted reproductive techniques (ART) (OR 1.87, 95% CI 1.70-2.06) were graded as suggestive evidence (class III). The other four risk factors including pre-pregnancy underweight (OR 1.38, 95% CI 1.12-1.70), preeclampsia (OR 1.73, 95% CI 1.47-2.04), uterine leiomyoma (OR 2.63, 95% CI 1.38-3.88), and marijuana use (OR 1.78, 95% CI 1.32-2.40) were graded as risk factors with weak evidence (class IV).

CONCLUSION

Maternal asthma, prior cesarean section, cocaine use, endometriosis, chronic hypertension, advanced maternal age, maternal smoking, and use of ART, pre-pregnancy underweight, preeclampsia, uterine leiomyoma, and marijuana use were risk factors associated with placental abruption. Although factors associated with placental abruption have been investigated, the current meta-analytic associations cannot disentangle the complex etiology of placental abruption mainly due to their low quality of evidence.

The main features of placental abruption: Clinical presentation and treatment

Placental abruption is defined as the premature separation of the placenta from the uterus. Rapid diagnosis and adequate medical intervention provide a good outcome, which is not possible in all countries. Any bleeding that occurs in the second half of pregnancy raises the suspicion of placental abruption, which is associated with fetal and maternal morbidity and mortality. The clinical picture and consequences for the fetus depend on the degree of bleeding and the amount of blood. Complete abruption leads to the disruption of fetal circulation and oxygenation, asphyxia, and stillbirth. In case of partial abruption, the consequences for the fetus depend on the degree of bleeding. In complete abruption, fetal death is inevitable unless an emergency cesarean delivery is undertaken.

The risk factors associated with placenta previa: An umbrella review

We evaluated in this umbrella review a systematic collection from meta-analyses conducted on risk factors associated with placenta previa. We searched PubMed, Scopus, and Web of Science until April 2021 assessing the risk factors associated with placenta previa. We calculated summary effect estimates odds ratio, relative risk, 95% CI, heterogeneity I², 95% prediction interval, small-study effects, excess significance biases, and sensitive analysis. The quality of the meta-analyses was evaluated with AMSTAR 2. We included nine studies in the present umbrella review. Seven risk factors including prior induced abortion (OR 1·36, 95% CI: 1·02, 1·69), prior spontaneous abortion (OR 1·77, 95% CI: 1·60, 1·94), male fetus (OR 1·2, 95% CI: 1·2, 1·3), smoking (OR 1·42, 95% CI 1·30, 1·54) (RR 1·27, 95% CI: 1·18, 1·35) advanced maternal age (OR 3·16, 95% CI: 2·79, 3·57), cesarean (OR 1·60, 95% CI: 1·44, 1·76) and ART (singleton pregnancy) (RR 3·71, 95% CI: 2·67, 5·16) were graded as highly suggestive evidence (class III). Endometriosis (OR 3·03, 95% CI: 1·50, 6·13) and maternal cocaine use (OR 2·9, 95% CI: 1·9, 4·3) were graded as risk factors with weak evidence (class IV). This study provides suggestive evidence about prior spontaneous abortion, prior induced abortion, male fetus, smoking, advanced maternal age, cesarean section, and assisted reproductive techniques (singleton pregnancy) as risk factors associated with placenta previa.

Iatrogenic factors contributed to the high rate of preterm birth in a community hospital

BACKGROUND

Preterm birth (PTB) rates have been increased significantly in recent years, mostly due to obstetric intervention. This study presents the incidence of PTB in community hospitals by assessing the association between pregnancy complications and iatrogenic PTB.

METHODS

A total of 6,693 pregnancies were enrolled in the Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University. They were divided into two groups (<35 and ≥35 years of age) to examine the effect of maternal age on PTB. Binary logistic and multiple linear regression analyses were used to assess the relationship between PTB and pregnancy complications.

RESULTS

This study provided the incidence of PTB and found that PP, PROM, and ICP increased the risk of PTB, indicating that pregnancy complications have led to the iatrogenic PTB and contributed to the high rate of PTB, especially in the group of advanced-age pregnant women. The prevalence of PTB was 9.53%. Placenta previa (PP), premature rupture of membranes (PROM), and intrahepatic cholestasis of pregnancy (ICP) were significantly associated with PTB. Among all the risk factors, hypertension, disease in pregnancy, premature PROM, and PP were observed as independent key factors for iatrogenic PTBs. In the advanced-age group, PP and pPROM increased the risk of PTB.

CONCLUSIONS

It is often necessary to terminate a pregnancy in community hospitals to balance the safety of the fetus and the maternal comorbid symptoms, which has led to nosocomial premature delivery. Therefore, high-risk pregnancies should be carefully evaluated and comprehensively treated with caution to balance the preterm rate and the safety of the pregnant woman and fetus, and the pros and cons of the outcomes, which has brought a challenge to an obstetrician to reduce the proportion of iatrogenic PTB.

Comparison of pregnancy outcomes between women of advanced maternal age (≥35 years) versus younger women in a tertiary care center in Saudi Arabia

BACKGROUND

Pregnancy in women aged 35 years or above is generally considered an advanced maternal age (AMA). AMA is associated with an increased rate of maternal and neonatal complications.

OBJECTIVES

Assess the effect of AMA on maternal and neonatal outcomes.

DESIGN

Analytical cross-sectional study of medical records.

SETTINGS

In-patient hospital tertiary care setting in Jeddah.

PATIENTS AND METHODS

All women who attended antenatal care and delivered at King Abdulaziz Medical City in Jeddah in the first half of 2018 were included in the study. Outcomes for women 35 years of age or older were compared with younger women. Significant factors in a univariate analysis were entered in a multiple logistic regression model to assess the association between AMA and outcomes.

MAIN OUTCOME MEASURES

Rates of maternal neonatal complications, analysis of factors associated with advanced maternal, gestational diabetes mellitus (GDM), cesarean delivery.

SAMPLE SIZE

1586 women.

RESULTS

Of the 1586 women, 406 were 35 years of age or older (25.6%), and 1180 were younger than 35 years. The AMA group had a significantly higher proportion of GDM (32.0% versus 13.2%, P<.001). The adjusted odds ratio (OR) for GDM was 2.6 (95% CI 2-3.5, P<.001.) compared with younger women in the multivariate logistic regression analysis. Older women had a higher rate of cesarean delivery (43.6% versus 30.8%, P<.001). The adjusted OR for cesarean vs. vaginal delivery was 1.5 (CI 1.2-1.9, P=.002).

CONCLUSION

Pregnancy in women 35 years or older was associated with an increased risk of GDM and cesarean delivery.

LIMITATIONS

Cross-sectional design, small sample size, single hospital.

CONFLICT OF INTEREST

None.

Advanced maternal age causes premature placental senescence and malformation via dysregulated α-Klotho expression in trophoblasts

Advanced maternal age (AMA) pregnancy is associated with higher risks of adverse perinatal outcomes, which may result from premature senescence of the placenta. α-Klotho is a well-known antiaging protein; however, its expression and effect on the placenta in AMA pregnancies have not yet been fully elucidated. The expression patterns of α-Klotho in mouse and human placentas from AMA pregnancies were determined by Western blotting and immunohistochemistry (IHC) staining. α-Klotho expression in JAR cells was manipulated to investigate its role in trophoblastic senescence, and transwell assays were performed to assess trophoblast invasion. The downstream genes regulated by α-Klotho in JAR cells were first screened by mRNA sequencing in α-Klotho-knockdown and control JAR cells and then validated. α-Klotho-deficient mice were generated by injecting klotho-interfering adenovirus (Ad-Klotho) via the tail vein on GD8.5. Ablation of α-Klotho resulted in not only a senescent phenotype and loss of invasiveness in JAR cells but also a reduction in the transcription of cell adhesion molecule (CAM) genes. Overexpression of α-Klotho significantly improved invasion but did not alter the expression of senescence biomarkers. α-Klotho-deficient mice exhibited placental malformation and, consequently, lower placental and fetal weights. In conclusion, AMA results in reduced α-Klotho expression in placental trophoblasts, therefore leading to premature senescence and loss of invasion (possibly through the downregulation of CAMs), both of which ultimately result in placental malformation and adverse perinatal outcomes.

Prelabor cesarean section: the role of advanced maternal age and associated factors

OBJECTIVE

to evaluate whether advanced maternal age (AMA) is associated with prelabor cesarean section and to identify the factors associated with prelabor cesarean section in AMA women, according to the mode of type of labor financing (private or public).

METHODS

Based on the Birth in Brazil survey, the research was conducted on representative sample of mothers for the country (Brazil), regions, type of hospital and location (capital or not), in 2011/2012. This study included 15,071 women from two age groups: 20-29 years and ≥ 35 years. The information was collected from interviews with puerperal woman, prenatal cards, and medical records of mothers and newborns. Multiple logistic regression modelling was used to verify the association between prelabor cesarean section and maternal, prenatal and childbirth characteristics, according to the mode of financing.

RESULTS

Our results showed a higher use of prelabor cesarean section for AMA (≥ 35 years) women in the public service (OR = 1.63; 95%CI 1.38-1.94) and in the private service (OR = 1.44; 95%CI 1.13-1.83), compared with women aged 20-29 years. In the adjusted model, we recorded three factors associated with the prelabor cesarean section in AMA women in both, public and private sectors: the same professional in prenatal care and childbirth (OR = 4.97 and OR = 4.66); nulliparity (OR = 6.17 and OR = 10.08), and multiparity with previous cesarean section (from OR = 5.73 to OR = 32.29). The presence of obstetric risk (OR = 1.94; 95%CI .44-2.62) also contributed to the occurrence of prelabor cesarean section in women who gave birth in the public service.

CONCLUSIONS

AMA was an independent risk factor for prelabor cesarean in public and private services. In the public, prelabor cesarean in AMA was more influenced by clinical criteria. Higher chance of prelabor cesarean section in nulliparous women increases the chance of cesarean section in multiparous women, as we showed in this study, which increases the risk of anomalous placental implantation.

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.

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.

Antenatal diagnosis of vasa previa: report of three cases in an African setting

Vasa previa is characterised by unprotected umbilical vessels that are crossing the internal cervical os or lying close to it. When vasa previa is not detected during antenatal period, the perinatal outcome could be grievous. Ultrasound is the modality of choice in detection of vasa previa. Despite the increasing availability of ultrasound in modern times, its use in diagnosing vasa previa still remain very low in Africa. We present the sonographic findings and perinatal outcomes of three cases of vasa previa which were detected antenatally within a period of nine months in an African setting.

Development of placental abnormalities in location and anatomy

Low‐lying placentas, placenta previa and abnormally invasive placentas are the most frequently occurring placental abnormalities in location and anatomy. These conditions can have serious consequences for mother and fetus mainly due to excessive blood loss before, during or after delivery. The incidence of such abnormalities is increasing, but treatment options and preventive strategies are limited. Therefore, it is crucial to understand the etiology of placental abnormalities in location and anatomy. Placental formation already starts at implantation and therefore disorders during implantation may cause these abnormalities. Understanding of the normal placental structure and development is essential to comprehend the etiology of placental abnormalities in location and anatomy, to diagnose the affected women and to guide future research for treatment and preventive strategies. We reviewed the literature on the structure and development of the normal placenta and the placental development resulting in low‐lying placentas, placenta previa and abnormally invasive placentas.

Could the Age Difference of a Single Calendar Year between Patients Undergoing IVF at 34, 35 or at 36 Years Old Affect the IVF Outcome? A Retrospective Data Analysis

Background and Objectives: Clinicians are called to overcome age-related challenges in decision making during In Vitro Fertilization (IVF) treatment. The aim of this study was to investigate the possible impact of a single calendar year difference among patients aged 34, 35 and 36 on IVF outcomes. Materials and Methods: Medical records between 2008 and 2019 were analyzed retrospectively. The study group consisted of women diagnosed with tubal factor infertility. Sample size was divided in three categories at 34, 35 and 36 years of age. Embryo transfer including two blastocysts was performed for every patient. Comparisons were performed regarding hormonal profile, response to stimulation, quality of transferred embryos, positive hCG test and clinical pregnancy rate. Results: A total of 706 women were eligible to participate. Two-hundred and forty-eight women were 34, 226 were 35 while the remaining 232 were 36 years old. Regarding the hormonal profile, the number of accumulated oocytes and the quality of embryos transferred, no statistically significant difference was documented between the three age groups. Women aged 34 and 35 years old indicated a significantly increased positive hCG rate in comparison to women aged 36 years old (p-value = 0.009, p-value = 0.023, respectively). Women aged 34 and 35 years old presented with a higher clinical pregnancy rate in comparison to those aged 36 years old (p-value = 0.04, p-value = 0.05, respectively). Conclusion: A calendar year difference between patients undergoing IVF treatment at 34 or 35 years of age does not appear to exert any influence regarding outcome. When treatment involves patients above the age of 35, then a single calendar year may exert considerable impact on IVF outcome. This observation indicates that age 35 may serve as a valid cut-off point regarding IVF outcome.

Impact of aging on obstetric outcomes: defining advanced maternal age in Barcelona

Background

Women of advanced maternal age (AMA) are a growing population, with higher obstetric risks. The Mediterranean population has specific characteristics different from other areas. Thus, the objective of this study was to establish a cut-off to define AMA in a selected mediterranean population coming from a tertiary referral private/mutual health hospital in Barcelona.

Methods

Retrospective cohort of euploid singleton pregnancies delivered from January 2007 to June 2017. Main maternal outcomes were: gestational diabetes, preeclampsia, placenta previa, c-section and prolonged hospitalization (≥ 7 days). Main adverse perinatal outcomes were: stillbirth, prematurity, preterm prelabor rupture of membranes, low birth weight, need of admission at a neonatal intensive care unit and perinatal mortality. Adjustment for confounding factors (smoking, previous comorbilities, parity, assisted reproductive techniques (ART) and obesity) was performed.

Results

A total of 25054 pregnancies were included. Mean maternal age was 34.7 ± 4.2 years, with 2807 patients in the group of age between 40 and 44 years (11.2%) and 280 patients ≥45 years (1.1%). Women at AMA had higher incidence of previous comorbilities (compared to the reference group of women < 30 years): prior c-section, chronic hypertension and obesity. In addition, they were more likely to use ART. After adjusting for confounding factors, maternal age was an independent and statistically significant risk factor for gestational diabetes (OR 1.66/2.80/3.14) for ages 30–39, 40–44 and ≥ 45 years respectively, c-section (OR 1.28/2.41/7.27) and placenta previa (OR 2.56/4.83) for ages 40–44 and ≥ 45 years respectively, but not for preeclampsia (neither early-onset nor late-onset). Risk of emergency c-section was only increased in women ≥45 years (OR, 2.03 (95% CI, 1.50–2.74). In the other groups of age, the increase in c-section rate was because of elective indications. Age ≥ 45 years was associated with iatrogenic prematurity < 37 weeks (OR 2.62, 95% CI 1.30–5.27). No other relevant associations between AMA and maternal or neonatal outcomes were found.

Conclusions

Maternal age is an independent risk factor for adverse obstetric outcomes. Age ≥ 40 years was associated to relevant increased risks and reveals to be an adequate cut-off to define AMA in our population.

Influence of Maternal Age on Selected Obstetric Parameters

Introduction In recent decades, there has been a continuous rise in the average age at which women give birth. A maternal age of 35 years and above is considered an independent risk factor in pregnancy and birth, due to higher rates of intervention. This study investigates the influence of maternal age on birth procedure, gestational age, and rate of interventions during delivery. The influence of maternal parity is also analyzed.

Material and Methods Data from the Austrian Register of Births was retrospectively collected and evaluated. The collected data was the data of all singleton live births in Austria between January 1, 2008 and December 31, 2016 (n = 686 272). Multiple births and stillbirths were excluded from the study. Maternal age and parity were analyzed in relation to predefined variables (birth procedure, gestational age, episiotomy in cases of vaginal delivery, epidural anesthesia in both vaginal and cesarean deliveries, and intrapartum micro-blood gas analysis). Statistical data was evaluated using (1) descriptive univariate analysis, (2) bivariate analysis, and (3) multinomial regression models.

Results The cesarean section rate and the rate of surgically-assisted vaginal deliveries increased with advancing maternal age, especially in primiparous women, while the rate of spontaneous deliveries decreased with increasing maternal age. A parity of ≥ 2 had a protective effect on the cesarean section rate. The rate of premature births also increased with increasing maternal age, particularly among primiparous women.

Discussion Although higher maternal age has a negative effect on various obstetric parameters, it was nevertheless not possible to identify a causal connection. Maternal age should not be assessed as an independent risk factor; other factors such as lifestyle or prior chronic disease and parity must be taken into consideration.

Cesarean section on a rise-Does advanced maternal age explain the increase? A population register-based study

Background

In Denmark, the cesarean section rate has increased by 49% between 1998 and 2015 and accounts for 21% of all births. Cesarean sections may cause short- as well as long-term consequences for both the mother and the child and impose further risks in future pregnancies. Delaying pregnancy until advanced maternal age at childbirth has been suggested as contributing to the increase. The proportion of women giving birth at 35 years or above increased from 15% (1998) to 21% (2015). Advanced maternal age at childbirth has been found to be related to increased pre-pregnancy morbidity and associated risk factors that may contribute to an increased risk of cesarean section. The aim of this study was to examine the association between advanced maternal age and cesarean section in a Danish population and the influence of demographic, anthropometric, health, and obstetric factors on this association.

Methods

This study draws on a national population-based cohort study of all Danish births between 1998 and 2015 (N = 1,122,964). Maternal age less than 30 years serves as reference with the following age categories: (30–34 years); (35–39 years), and (40 years and above). The primary outcome was a cesarean section. Multivariate regression models with adjustment for demographic, health, pregnancy, fetal, and obstetric characteristics were performed with the results further stratified by parity.

Results

In general, a positive association between advanced maternal age and cesarean section was found. Only minor changes in the risk estimate occurred after adjustment for relevant confounders. In comparison with the reference category, nulliparous women aged 35-39- years had twice the risk for cesarean section (adjusted odds ratio (AOR) 2.18, 95% confidence interval (CI) [2.11–2.26]) whereas for women of 40 years or above, the risk was more than tripled (AOR 3.64, 95% CI [3.41–3.90]). For multiparous women aged 35-39-years the risk was more moderate, but still with an AOR of 1.56, 95% CI [1.53–1.60], and for those 40 years and above, the AOR was 2.02, 95% CI [1.92–2.09].

Conclusions

Overall, cesarean section increased with increasing maternal age. Adjustment for maternal and obstetric risk factors had only a minor influence on the association. The association was stronger in nulliparous women compared to multiparous women. Given the lack of impact of demographic and health risks on the relationship between maternal age and cesarean section, the authors suggest obstetric culture could be added to the list of risk factors for a cesarean. Future research on obstetric culture is recommended as are studies on a possible age-related decrease in the ability to maintain the progression of labor.

Trial registration

The study uses depersonalized register data and has been approved by the Danish Data Protection Agency (2015-41-4168).