The impact of parity on perinatal outcomes in pregnancies complicated by advanced maternal age

Longitudinal trends in fertility in women of advanced maternal age in the United States and Sweden from 1935-2018 and comparison to maternal mortality ratios

Advanced maternal age (AMA, >35 years at delivery) confers maternal and foetal risks, particularly with age >45 years and nulliparity, but longitudinal comparative data on age- and parity-specific AMA fertility is lacking. We used the Human Fertility Database (HFD), a publicly available, international database, to analyse fertility in US and Swedish women aged 35-54 from 1935 to 2018. Age-specific fertility rates (ASFR), total birth counts, and proportion of AMA births were evaluated across maternal age, parity, and time, and compared to maternal mortality rates during the same time. In the US, total AMA births nadired in the 1970s, and have risen since. Until 1980, most AMA births were to women completing parity 5 or higher; since then, most have been to low parity women. While ASFR in 35 to 39 year olds was highest in 2015, ASFR in women 40-44 and 45-49 were highest in 1935, though they have been rising recently, especially in low-parity women. While the same AMA fertility trends were seen in the US and Sweden from 1970-2018, maternal mortality rates have risen in the US despite remaining low in Sweden. Although AMA is known to contribute to maternal mortality, this discrepancy merits further consideration.

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.

Maternal and perinatal complications according to maternal age: a systematic review and meta-analysis

OBJECTIVE

To evaluate the risk levels for maternal and perinatal complications at >=40, >=45, >50 years old compared to younger controls METHODS: Electronic databases were searched from their inception until March 2021. We included studies reporting pregnancy outcome in pregnant women 40, 45 and 50 years or older compared with controls at the time of delivery. Case reports, and case series were excluded. The primary outcome was the incidence of stillbirth. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI). Heterogeneity was measured using I-squared (Higgins I² ). Subgroup analyses in women older than 45 years and in those older than 50 years were performed.

RESULTS

27 studies, including 31,090,631, were included in the meta-analysis. The overall quality of the included studies was moderate to high. The vast majority of the included studies were retrospective cohort studies (21/27), four were population-based studies, and two were cross sectional studies. Women ≥ 40 years had significantly higher risk of stillbirth (RR 2.16, 95% CI 1.86 to 2.51), perinatal mortality, IUGR, neonatal death, admission to NICU, preeclampsia, preterm delivery, cesarean delivery, and maternal mortality compared to <40 yo women (RR 3.18, 95% CI 1.68 to 5.98). The increased risk for maternal mortality was 42.76 and 11.60 for women older than 50 years and for those older than 45 years, respectively, while those for stillbirth was 3.72 and 2.32. The risk of stillbirth and cesarean delivery was significantly higher in women >45 years compared to those aged 40-45, and in those >50 years compared to those aged 45-50. The risk of maternal mortality was significantly higher in women >50 years compared to those aged 40-45 (RR 60.40, 95% CI 13.28 to 274.74).

CONCLUSIONS

The risk of stillbirth, cesarean delivery, and maternal mortality increases with advancing maternal age. The risk ratio for maternal mortality was 3.18, 11.60, and 42.76 in women older than 40, older than 45, and older than 50 years, respectively. These data should be used when women with advanced maternal age are counselled regarding their risk in pregnancy.

Differential effect of pre-pregnancy low BMI on fetal macrosomia: a population-based cohort study

BACKGROUND

The differential effect of pre-pregnancy low BMI on macrosomia has not been fully addressed. Herein, we conducted a city-wide population-based cohort study to illuminate the association between pre-pregnancy low BMI and macrosomia, stratifying by maternal age, parity, and GDM status.

METHODS

All pregnant women who paid their first prenatal visit to the hospital in Qingdao during August 1, 2018, to June 30, 2020, were recruited to this study. The interactive effect of maternal age and pre-pregnancy low BMI on macrosomia was evaluated using logistic regression models, followed by strata-specific analyses.

RESULTS

A total of 105,768 mother-child pairs were included, and the proportion of fetal macrosomia was 11.66%. The interactive effect of maternal pre-pregnancy BMI and age was statistically significant on macrosomia irrespective of parity (nullipara: P_adjusted=0.0265; multipara: P_adjusted=0.0356). The protective effect of low BMI on macrosomia was most prominent among nullipara aged 35 years and above (aOR=0.16, 95% CI 0.05-0.49) and multipara aged 25 years and below (aOR=0.17, 95% CI 0.05-0.55). In nullipara without GDM, the risk estimates gradually declined with increasing conception age (20-to-24 years: aOR=0.64, 95% CI 0.51-0.80; 25-to-29 years: aOR=0.43 95% CI 0.36-0.52; 30-to-34 years: aOR=0.40 95% CI 0.29-0.53; and ≥35 years: aOR=0.19, 95% CI 0.06-0.60). A similar pattern could also be observed in nullipara with GDM, where the aOR for low BMI on macrosomia decreased from 0.54 (95% CI 0.32-0.93) in pregnant women aged 25-29 years to 0.30 (95% CI 0.12-0.75) among those aged 30-34 years. However, younger multiparous mothers, especially those aged 25 years and below without GDM (aOR=0.21, 95% CI 0.06-0.68), were more benefited from a lower BMI against the development of macrosomia.

CONCLUSIONS

Maternal low BMI is inversely associated with macrosomia irrespective of maternal age and parity. The impact of pre-pregnancy low BMI on macrosomia varied by maternal age and parity. The protective effect of a lower maternal BMI against fetal macrosomia was more prominent in nulliparous mothers aged 35 years and above, whereas multiparous mothers younger than 25 years of age were more benefited.

Neonatal Outcome of Babies Born to Women 40 Years and Older in a Jamaican Birth Cohort

OBJECTIVE

 The study aimed to determine the outcome of babies born to women ≥40 years in a Jamaican birth cohort.

PATIENTS AND METHODS

 Maternal demographic data and neonatal data for women ≥40 years who delivered live singleton babies and their younger counterparts aged 20 30 years were extracted from the JA KIDS birth cohort dataset. Outcome measures were preterm birth, low birth weight, very low birth weight, extremely low birth weight, macrosomia, a low 5-minute Apgar score <7, admission to the neonatal unit, and neonatal death. Descriptive analyses were performed; statistical significance was taken at the level p <0.05.

RESULTS

 A total of 5,424 women and their babies were entered into the study, 5,099 (94%) women were aged 20 to 30 years (mean age ± standard deviation [SD]: 24.5 ± 3.2 years) and 325 (6%) were aged ≥40 years (mean age ± SD: 41.5 ± 1.6 years). A greater percentage of preterm babies (18%) were born to women ≥40 years than to their younger counterparts (14%; p = 0.04). There was no difference in the proportion of low birth weight infants, very low birth weight infants, or extremely low birth weight infants born between the two groups (p > 0.05). There was also no significant difference in the proportion of babies who were macrosomic and in those who had a low 5-minute Apgar score <7. There were 866 (16%) neonatal admissions, 67/325 (21%) of these babies were born to women aged ≥40 years and 799/5,099 (16%) were born to their younger counterparts (p = 0.01). The commonest reason for admission was prematurity. While 60 babies died, there was no significant difference between both groups with 56 (1%) born to women 20 to 30 years and 4 (1%) born to women ≥40 years (p = 0.48).

CONCLUSION

 Adverse outcomes noted for babies born to women ≥40 years were prematurity and the need for neonatal admission. However, no excess mortality was recorded.

KEY POINTS

· Women 40 years and older are more likely to have a chronic illness such as hypertension and diabetes and to have an operative delivery.. · Babies born to women 40 years and older are more likely to be late premature infants and require neonatal admission.. · However, there is no increased risk of neonatal mortality..

Adverse maternal and perinatal pregnancy outcomes related to very advanced maternal age in primigravida and multigravida in the Netherlands: A population-based cohort

INTRODUCTION

The age at which women give birth is rising steadily in the western world. Advanced maternal age has been associated with adverse pregnancy outcomes. We assessed the association between advanced maternal age and the risk of adverse maternal and perinatal outcome in primigravid and multigravid women.

MATERIAL AND METHODS

The study was a population-based cohort study and included women giving birth between January 2000 and December 2018 using data from the Dutch perinatal registration of Perined. Women were divided into age groups. We compared outcomes between women of 40-44, 45-49, and over 50 years old (the study groups) with women of 25-29 years old (reference group), stratified for parity. We employed multivariable regression to correct for possible confounders including methods of conception, multiple pregnancies, ethnicity, and socio-economic status. Our primary outcomes were maternal and perinatal mortality. Secondary outcomes included common maternal and perinatal complications, as well as cesarean section rate.

RESULTS

A cohort of 3 700 326 women gave birth during the study period. Of these women, 3.2% were above 40 years of age. Maternal mortality was rare in all groups, but significantly higher in multigravid women over 50 years old. Perinatal mortality was significantly higher in all pregnancies of women over 40 years old, but not for primigravida over 50 years old. The most notable results with the steepest increase were in maternal complications. Both primigravida and multigravida over 40 years old were at a two times higher risk of perinatal mortality, cesarean section, gestational diabetes, hypertensive disorders, and a low Apgar score after 5 minutes. The risk for women over 45 was almost tripled for perinatal mortality and gestational diabetes and six times higher for cesarean section. Women over 50 years old had a seven times higher risk of cesarean section, a four times higher risk of gestational diabetes, postpartum hemorrhage, and neonatal intensive care unit admission, and a 10 times higher risk of hypertensive disorders.

CONCLUSIONS

The risk of adverse maternal and perinatal outcomes for women over 40 years old surges as age increases. A novel aspect was the consistent increased risks not only for primigravid women but also for multigravida.

Maternal Diet Quality, Body Mass Index and Resource Use in the Perinatal Period: An Observational Study

The impact of pre-pregnancy obesity and maternal diet quality on the use of healthcare resources during the perinatal period is underexplored. We assessed the effects of body mass index (BMI) and diet quality on the use of healthcare resources, to identify whether maternal diet quality may be effectively targeted to reduce antenatal heath care resource use, independent of women’s BMI. Cross-sectional data and inpatient medical records were gathered from pregnant women attending publicly funded antenatal outpatient clinics in Newcastle, Australia. Dietary intake was self-reported, using the Australian Eating Survey (AES) food frequency questionnaire, and diet quality was quantified from the AES subscale, the Australian Recommended Food Score (ARFS). Mean pre-pregnancy BMI was 28.8 kg/m² (range: 14.7 kg/m²–64 kg/m²). Mean ARFS was 28.8 (SD = 13.1). Higher BMI was associated with increased odds of caesarean delivery; women in obese class II (35.0–39.9 kg/m²) had significantly higher odds of caesarean delivery compared to women of normal weight, (OR = 2.13, 95% CI 1.03 to 4.39; p = 0.04). Using Australian Refined Diagnosis Related Group categories for birth admission, the average cost of the birth admission was $1348 more for women in the obese class II, and $1952 more for women in the obese class III, compared to women in a normal BMI weight class. Higher ARFS was associated with a small statistically significant reduction in maternal length of stay (RR = 1.24, 95% CI 1.00, 1.54; p = 0.05). There was no evidence of an association between ARFS and mode of delivery or “midwifery-in-the-home-visits”.

Pregnancy complications among nulliparous and multiparous women with advanced maternal age: a community-based prospective cohort study in China

Background

This study aimed to evaluate the incidence rates and risks of pregnancy complications among nulliparous and multiparous women with advanced maternal age (AMA, ≥35 years) in China.

Methods

We performed a community-based prospective cohort study of 10,171 pregnant women in selected two sub-districts and 11 towns of Liuyang from 2013 to 2015. All subjects were followed up from the first prenatal care (at ≤12 weeks) to delivery, and risks of pregnancy complications were compared by parity and maternal age groups.

Results

Among nulliparas, women with AMA showed significantly increased risks for gestational hypertension (OR 8.44, 95%CI 1.68–2.88), preeclampsia/eclampsia (OR 9.92, 95%CI 4.87–18.78), premature rupture of membrane (OR 6.84, 95%CI 2.00–17.69), as compared to women in the 20–29-year age group. Among multiparas with AMA, increased risks were found for gestational diabetes mellitus (OR 3.29, 95%CI 1.76–5.94), anemia (OR 1.85, 95%CI 1.25–2.69), polyhydramnios (OR 3.29, 95%CI 1.56–6.64), premature rupture of membrane (OR 5.14, 95%CI 2.12–12.29), and preterm labor (OR 1.89, 95CI 1.42–2.50).

Conclusions

Women with AMA were associated with increased risks of pregnancy complications, and complications with increased risks differed in nulliparas and multiparas. Women with AMA should be identified as a high-risk group in clinical practice.

Advanced maternal age and factors associated with neonatal near miss in nulliparous and multiparous women

The early neonatal period accounts for approximately half of the deaths of young children under one year of age, and the neonatal near miss can recognize factors causing this high number of deaths. Thus, the aim of this study is to determine whether advanced maternal age increases the chance of neonatal near miss, in addition is to identify which factors are associated with the neonatal near miss, stratified by parity. Data are from the 2011-2012 Birth in Brazil study, which used a national population-based sample of 15,092 newborns of women between 20-29 and 35 years of age or more (advanced maternal age). Multiple logistic regression was performed to test the association between neonatal near miss and prenatal and childbirth variables, pre-gestational diseases, obstetric history and socioeconomic characteristics, stratified by parity. Advanced maternal age was to be statistically associated with neonatal near miss in nulliparous (OR = 1.62; 95%CI: 1.05-2.50) and multiparous (OR = 1.51; 95%CI: 1.20-1.91) when compared to women 20-29 years of age. For nulliparous women, the main variables statistically associated with neonatal near miss were multiple gestation (OR = 8.91) and hypertensive disease (OR = 2.57), whereas forceps-assisted vaginal delivery (OR = 7.19) and multiple gestation (OR = 4.47) were the variables associated for multiparous women. Neonatal near miss has been shown to be connected with access to health services for childbirth, gestational complications and maternal characteristics, mainly advanced maternal age. Therefore, to properly monitor and classify maternal gestational risk, to control gestational complications during prenatal care, and to correctly refer these women to childbirth care should be priority strategies for healthcare services.

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

Background

Pregnancy at advanced maternal age has become more common in both developed and developing countries over the last decades. The association between adverse perinatal outcomes and advanced maternal age has been a matter of controversy in several studies. The objective of this study is to investigate the impact of advanced maternal age on perinatal and neonatal outcomes of nulliparous singleton pregnancies.

Methods

Records of patients admitted to the Department of Obstetrics and Gynecology, University of Cukurova School of Medicine, between January 2011 and July 2015 for routine mid-trimester fetal ultrasonography were retrospectively reviewed. The control (age: 18–34 years), advanced maternal age (35–39 years), and very advanced maternal age (> 40 years) groups included 471, 399, and 87 women, respectively.

Results

Gestational diabetes, gestational hypertension, and cesarean delivery rates were more common in the very advanced maternal age group, with compared with the advanced maternal age and the younger age group. There were no significant differences in regarding rates of spontaneous preterm delivery before 34 weeks of gestation, prolonged rupture of membranes, large for gestational age infants, and operative vaginal delivery rates between the groups. Also, there were no significant differences regarding in APGAR scores, the rate of low birth weight infants, and neonatal morbidity rates between the groups. However, admission to the neonatal intensive care unit requirement was more common in the two advanced maternal age groups compared with the control group.

Conclusion

Advanced maternal age is a risk factor for gestational diabetes mellitus, gestational hypertension, preeclampsia, small for gestational age infants, spontaneous late preterm delivery, and cesarean section, with significant potential clinical implications.

Neonatal Outcome of Babies Born to Women 40 Years and over at the University Hospital of the West Indies 2012-2013

AIM

This article aims to determine neonatal outcome of babies born to women ≥40 years at the University Hospital of the West Indies.

METHODS

This was a matched retrospective cohort study looking at the outcome of all babies born to women ≥40 years and control babies born to women aged 20-30 years at the University Hospital of the West Indies over a 2-year period. Maternal and neonatal demographic data and course of admission for admitted neonates were recorded. Descriptive analyses were performed.

RESULTS

One hundred and ninety-eight neonates were born to women ≥40 years and 208 to their younger counterparts, M:F 1:1.2. There was no difference in the number of preterm or low birth weight infants, the number of neonates with a low 5 min Apgar score <7, the number of neonates admitted or the number of neonates who died between women ≥40 years and their younger counterparts (p > 0.05).

CONCLUSION

No difference in adverse neonatal outcome was noted between women ≥40 years and their younger counterparts.

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

This study aimed to investigate the existence and magnitude of the association between advanced maternal age (AMA) and occurrence of placenta praevia (PP) and placental abruption (PA) among nulliparous and multiparous women, by a systematic review and meta-analysis. We searched articles published between January 1, 2005 and December 31, 2015, in any language, in the following databases: PubMed, Scopus, Web of Science, and LILACS. Women were grouped into two age categories: up to 34 years old and 35 years or older. The Newcastle-Ottawa Scale was used to evaluate the methodological quality of the studies. A meta-analysis was conducted for the PP and PA outcomes, using a meta-regression model to find possible covariates associated with heterogeneity among the studies and Egger's test to assess publication bias. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) system (CRD42016045594). Twenty-three studies met the criteria and were included in the meta-analysis. For both outcomes, an increase in age increased the magnitude of association strength, and PP (OR = 3.16, 95%CI: 2.79-3.57) was more strongly associated with AMA than PA (OR = 1.44, 95%CI: 1.35-1.54). For parity, there was no difference between nulliparous and multiparous women considered older for the PP and PA outcomes. Our review provided very low-quality evidence for both outcomes, since it encompasses observational studies with high statistical heterogeneity, diversity of populations, no control of confounding factors in several cases, and publication bias. However, the confidence intervals were small and there is a dose-response gradient, as well as a large magnitude of effect for PP.

Effects of mother related factors on perinatal outcomes-a study of mothers seeking antenatal care at public and non-public health facilities in Kisii County, Kenya

The study sought to determine clientlevel and facility-level factors that affect perinatal outcomes among women attending comparable public (government owned) and non-public health facilities (non-government owned) in Kisii County-Kenya in the context of free maternity care. A total of 365 pregnant mothers recruited in 4 health facilities during their ANC visit and followed up to 2 weeks post-delivery but only 287 attended all follow-up visits. Study subjects were recruited proportionate to number of deliveries each of the facilities had conducted in the preceding 6 months. The dependent variable was perinatal outcome; independent variables were demographic and clinical factors. Analysis was done using χ², logistic regression, paired t and McNemar’s tests. Maternal BMI and a mother’s parity were statistically correlated with perinatal outcome (χ²= 8.900, d.f =3, P=0.031 and (χ²= 13.232, d.f =4, P=0.039) respectively. Mothers with 1 parity were 4.5 times more likely to have normal perinatal outcomes (OR =4.5, 95% CI 2.25-14.29, P=0.012). There was a significant relationship between a mother’s knowledge of pregnancy-related issues and the baby’s weight (t=-67.8 d.f. 213 P<0.001). Mothers’ knowledge on pregnancy issues and spousal involvement influences perinatal outcomes. Dietary Diversity Score (DDS) of a mother does not have a direct influence on the outcome of a pregnancy. There is need to focus on maternal factors that affect perinatal outcomes besides free maternity care.

Is primiparity a risk factor for advanced maternal age pregnancies?

OBJECTIVE

Currently, more women are delaying childbearing until their 40s.This study compared the pregnancy and maternal features, pregnancy and foetal outcomes between multiparous and primiparous patients. We compared the same factors between assisted reproductive technology (ART) and non-ART primiparous patients because of the high proportion of ART used in the primiparous patients.

METHODS

The study retrospectively examined 1680 patients, 35 years of age and older, between March 2008 and February 2015.

RESULTS

Comparing the features of these two groups, there was an increased incidence of employment and the use of ART in primiparous patients, while birthweight tended to be higher in the multiparous group. There were no significant differences in pregnancy complications other than hypertension disorders, such as pre-eclampsia and HELLP syndrome, which were significantly more frequent in primiparous patients. The rates of foetal growth retardation and perinatal death were significantly higher in primiparous women. Comparison of the data between ART and non-ART primiparous patients indicated that the ART group had a higher initial body mass index and a lower smoking rate. No significant differences in pregnancy complications or foetal outcome were observed between these two groups.

CONCLUSION

Primiparity is associated with increased pregnancy and foetal complications in advanced age pregnancies. However, the use of ART in this age group does not seem to be an additional risk factor.