ABSTRACTThe aim of this research was to compare the pregnancyoutcome and delivery complications in women 40 years or older to that of women20 to 30 years old .Advanced maternal age, compared with younger age, wasassociated with significantly higher rates of preterm delivery, cesareandelivery (CS), and the occurrence of one or more antepartum complications. Whenthe two groups were subdivided according to parity, rates of preterm delivery,CS, preeclampsia, gestational diabetes, chronic hypertension, and laborinduction were each significantly higher among older multiparas compared withyoung multiparas. However, only preterm delivery, CS rates, and uterinefibroids were found to be significantly higher in older nulliparous comparedwith young nulliparous women. We conclude that multiparous women at least 40years old have a higher antepartum complication rate including intrauterinefetal death compared with younger women.
KEYWORDAdvancedmaternal age – pregnancy outcome INTRODUCTIONAn increasing number ofwomen are delaying their childbirth because of social, economical, andeducational factors. In developed countries, women are more involved with theirprofessional career and thus delay their childbearing until the fourth andfifth decade, and most of them are nulliparous at the time of delivery. Indeveloping countries, most of these women are multiparous. Women above the age35 have traditionally been termed “elderly gravidas.
”1 2 Recently, more interesthas been focused on women who are more than 40 years old especially with thewidespread use of assisted reproductive technologies. There are several reportsof pregnancies with egg donation even in postmenopausal women above the age of50.3 4 Only a few years ago,such women were discouraged from getting pregnant because of the highermaternal and perinatal morbidity and mortality.1 2 5 However, recently manystudies have shown a favorable outcome in such elderly pregnant women.
6 7 We, thus, conducted ourresearch to try to determine the frequency of adverse obstetricaloutcome in women 40 years or older in comparison with women 20 to 30 years old .DISCUSSIONUntil recently, advanced maternalage was considered one of the risk factors for an adverse maternal andperinatal outcome. However, more women in developed countries are delayingtheir childbirth for various reasons and recent studies have reported a morefavorable outcome. 6 7 In developing countries, pregnanciesabove 40 are, in most cases, just a continuation of the reproductive life ofthese women.This research is to compare agroup of women at least 40 years old, to a matched group, aged 20 to 30, whoare usually considered to have the lowest maternal and perinatal morbidity andmortality. Pregnancy complications weretwice more likely to occur in elderly pregnant women compared with young age.
Preterm deliveries were twice as common in older women. The difference inpreterm delivery rate remained significantly higher in elderly even afterexcluding patients with medical or obstetrical indications for induction,indicating an inherent increased risk for spontaneous preterm labor in elderlywomen. The incidence of gestationaldiabetes, preeclampsia and chronic hypertension was also higher in elderlypregnant women. It is worth mentioning that testing for gestational diabetes isuniversal for all our obstetrical patients regardless of age. Thus, the higherincidence of gestational diabetes observed in the elderly women is notsecondary to understating the incidence in the younger women.
The reasons forthis increased frequency of complications vary according to the complication. Chronic hypertension andgestational diabetes are easier to explain, as both are affected by age. Theincidence of chronic hypertension increases with age, and older women have moredifficulty with their carbohydrate metabolism with most studies suggesting atleast doubling of the incidence. 7 8 Furthermore,preeclampsia is reported to be more frequent at the extremes of reproductiveage. The etiology of preeclampsia is still unclear and it is frequentlydifficult to separate preexisting hypertension from pregnancy inducedhypertension.
In fact, some studies did not find a higher incidence ofpreeclampsia in older women. 9In our chain, preeclampsia, chronichypertension, and gestational diabetes were more frequent in multiparouselderly women compared with multiparous younger women. This did not hold truefor nulliparous. The cesarean section rate was 2.5 times higher compared withyoung age and this was true for both nulliparous and multiparous patients.
Thishas been reported in virtually all studies. 7 10 The most frequent indicationsin both groups were repeat CS, followed by non reassuring fetal tracing, andabnormal presentation. However, the chance of delivering by CS was almost doubled for any indicationin elderly compared with young. In some studies the incidence of abnormal laboris higher in older patients, the basis of which is not clear.6 This was not demonstrable in ourresearch.
The presence of a higher rate of obstetrical complications andchronic medical illnesses in the elderly women might have contributedindirectly to the higher incidence of CS. These patients are more likely tohave elective repeat CS and abnormal fetal heart tracings. There was no difference in the percentage ofApgar score <7 at 5 minutes in both groups which might be explained by thefact that physicians might have a lower threshold to perform a CS in this groupof patients with a ``precious pregnancy.'' Perinatal outcome was alsosignificantly affected by age. Although the incidence of intrauterine growthrestriction was similar in both groups in our series, older women had a higherincidence of intrauterine fetal death and infants with Apgar scores <7 at 5minutes and about 61.5% of cases of IUFD occurred without an identifiable riskfactor in the advanced maternal age group versus none in the young.
Congenital malformations werediagnosed antenatally in most of the elderly women and were found to be similarin oldand young age. Both minor and major anomalies, defined as anomalies that had amajor impact on neonatal morbidity or mortality such as polycystic kidneydisease, were included. Only a minor anomaly (cleft lip) was incidentally foundin all the intrauterine fetal deaths that occurred in the elderly group. Thus,congenital anomalies were not a major contributor to the higher incidence offetal death seen in the elderly woman. In some studies, the incidence ofchromosomal abnormalities was similar in elderly and younger women, and thiswas attributed to the aggressive prenatal genetic counseling and screening thatthese women have in developed countries.6 In our population, theacceptance rate of prenatal diagnosis is low especially in the youngpopulation11 .Furthermore, the results of themultiple regression analysis emphasized the importance of each variable interms of the outcome. It is evident that as far as the high CS rate and thepreterm delivery, age and obstetrical complications are more important thanparity.
Medical complication are more important than age in relation to thedevelopment of obstetrical complications. CONCLUSIONWe conclude that multiparous women at least 40 yearsold have a higher antepartum complication rate including intrauterine fetaldeath compared with younger women.