Advanced maternal age is associated with adverse obstetric and perinatal outcomes compared to females in the 20-34-year age group.
This finding was made in an original article on “Advanced maternal age and perinatal outcomes in two tertiary care maternity hospitals in Colombo” which was authored by T. Jayatunge (Acting Consultant Neonatologist at the Teaching Hospital, Ratnapura), S. Kumara (Consultant Neonatologist at the Castle Street Hospital for Women) and N. Lucas (Consultant Neonatologist at the Professorial Unit of the De Soysa Hospital for Women and Senior Lecturer of the Colombo University's Medical Faculty's Paediatrics Department) and published in the Sri Lanka Journal of Child Health 51st Volume's Second Issue in June 2022.
Advanced maternal age
Advanced maternal age is defined in M. Laopaiboon, P. Lumbiganon, N. Intarut, R. Mori, T. Ganchimeg, J.P. Vogel, J.P. Souza and A.M. Gülmezoglu's “Advanced maternal age and pregnancy outcomes: A multi-country assessment”, as a pregnancy in females aged 35 years or older at the time of the booking visit, and this survey in 29 countries including in Africa, Asia, the Middle East and Latin America reported that the same was seen in 12.3%. In Sri Lanka, in 2013, per T. Dias, E. Wijesinghe, S. Abeykoon, P. Ganeshamoorthy, S. Kumarasiri, M. Kodithuwakku, C. Gunewardena and T. Padeniya's “Pregnancy outcome in extremes of reproductive age at a tertiary care hospital”, 15.8% pregnancies with advanced maternal age were reported. As observed in M. Carolan and D. Frankowska's “Advanced maternal age and adverse perinatal outcome: A review of the evidence”, over the past few decades, there is a rising trend in females delaying childbearing for educational and socio-economic reasons in all countries. An Australian study notes that maternal and foetal adverse outcomes of advanced maternal age include gestational diabetes mellitus, pregnancy-induced hypertension, iron deficiency anaemia, assisted vaginal or caesarean section deliveries, preterm birth, stillbirth, and low birth weight while a higher incidence of the Down syndrome was found in such pregnancies. Maternal and perinatal outcomes in pregnancies with advanced maternal age, per D. Weerasekera and S.G. Udugama's “Pregnancy at 40 and over: A case control study in a developing country”, an Asian study, L.C. Kenny, T. Lavender, R. McNamee, S.M. O’Neill, T. Mills and A.S. Khashan's "Advanced maternal age and adverse pregnancy outcome: Evidence from a large contemporary cohort”, A.A. Pawde, M.P. Kulkarni and J. Unni's “Pregnancy in women aged 35 years and above: A prospective observational study”, Y. Wang, T. Tanbo, T. Åbyholm and T. Henriksen's “The impact of advanced maternal age and parity on obstetric and perinatal outcomes in singleton gestations”, I. Mutz-Dehbalaie, M. Scheier, S. Jerabek-Klestil, C. Brantner, G.H. Windbichler, H. Leitner, D. Egle, A. Ramoni and W. Oberaigner's “Perinatal mortality and advanced maternal age”, and E. Guesdon, A. Vincent-Rohfritsch, S. Bydlowski, P. Santulli, F. Goffinet and C. Le Ray's “Oocyte (an immature ovum, or egg cell) donation recipients of very advanced age: Perinatal complications for singletons and twins”, differed from country to country, according to the availability and accessibility of healthcare facilities and underlying socio-demographic factors.
Adverse effects
Jayatunge et al.'s prospective cohort study was conducted from 1 March to 31 July 2018, to appraise the association of advanced maternal age pregnancy with adverse obstetric and perinatal outcomes in the Castle Street Hospital for Women and the De Soysa Hospital for Women. All pregnant females aged 20 years or more on the date of the booking visit, admitted to the said Hospitals for confinement or in labour at the time of admission, with a gestation of 22 weeks or more were included. Gestation was calculated based on the ultrasound scans done from 8-13 gestational weeks. Pregnant females admitted following trauma (falls, severe unintentional burns, road traffic accidents, attempted suicide, homicide, etc.), which may adversely affect pregnancy outcomes were excluded. Postnatal females and newborns were followed up during the stay in the two Hospitals and at the end of seven days of age. If the mother or the baby was discharged before day seven, they were given the option to visit the clinic at the same Hospitals or the Medical Officer of Health (MOH) office. During this visit, the baby was assessed for weight gain, breastfeeding and other concerns.
A total of 648 pregnant females participated including 326 females who were 35 years or older and 322 females who were in the 20-34 age group. The mean age of the females in the 35 years or older group was 37 years and it was 28 years in the 20-34-year age group. There was no significant difference in ethnicity, the employment status, marital status or highest educational level between the two groups. However, a monthly family income of more than Rs. 50,000 was 1.46 times more likely with females of advanced maternal age compared to the 20-34-year age group.
A notably greater proportion of females with advanced maternal age had subfertility, postponed the current pregnancy and delivered their baby via a caesarean delivery in this pregnancy compared to those aged 20-34 years. Moreover, females with advanced maternal age were 3.45 times more likely to have pregnancy induced hypertension and 1.9 times more likely to have gestational diabetes mellitus compared to those aged 20-34 years. Pregnancy induced hypertension and gestational diabetes mellitus during the current pregnancy were not significant among the two age groups after adjusting for confounders. Females with advanced maternal age were noted to have a significantly higher income, a significantly higher rate of postponement of the current pregnancy, a significantly higher risk of subfertility, undergoing a caesarean delivery and a preterm delivery after adjusting for confounders. There was a significantly higher rate of neonatal unit admissions in females with advanced maternal age compared to the females in the 20-34-year age group. There were no significant differences between the birth weight, five minute Apgar (a quick way for doctors to evaluate the health of all newborns at one and five minutes after birth and in response to resuscitation) scores, stillbirths, early neonatal deaths, congenital abnormalities, or re-admissions during the early perinatal period between the two groups. Respiratory distress was the commonest indication for admission to a neonatal unit, while feeding problems were the commonest indications for re-admission. There was no significant difference between the reasons for admission or readmission among the advanced maternal age and the 20-34-year age group.
The study showed that pregnant females with advanced maternal age were more likely to undergo a caesarean delivery, than females 20-34 years of age. This may be, according to a Bangladeshi study, due to the higher prevalence of pregnancy induced hypertension, gestational diabetes mellitus or having a bad obstetric history, like previous miscarriages or subfertility. Pregnancy induced hypertension was not significantly different between the two groups in the current study. Weerasekera et al.'s study in 2003 reported a greater incidence of pregnancy induced hypertension (27.3% versus 12%) in pregnancies at 40 years and over. The risk for gestational diabetes mellitus was 1.71 times higher among pregnant females above 40 years in a United States study. The instant study did not show a significant difference between the two groups in terms of the risk for gestational diabetes mellitus. The current study reported a significantly higher risk of preterm delivery in females with advanced maternal age. The present study showed that advanced maternal age was not a significant risk factor for low birth weight. There was no significant difference in the five minute Apgar score between the advanced maternal age group and the 20-34-year age group in this study population.
Awareness
With expanding opportunities for higher education, careers, and economic independence, more young females tend to delay the childbearing age above 35 years. This study showed that 12.2% of females in advanced maternal age delayed their current pregnancy compared to 3.1% in the 20-34 group; however, the commonest reason for postponement was the partner being away for work. In this study, a significantly greater rate of neonatal unit admissions was noted in the advanced maternal age group compared to the 20-34-year age group with no significant difference in re-admission.
Jayatunge et al. emphasise that awareness must be raised about the complications associated with advanced maternal age in order to ensure that females make an informed choice about the timing of their pregnancy. "The importance of contraception must be emphasised in females with advanced maternal age in order to prevent unwanted pregnancies. Pregnant females with advanced maternal age should be educated about the higher risk of complications, how to identify them, when to seek help and the importance of meticulous antenatal care so as to improve the maternal and perinatal outcome," Jayatunge et al. noted.