Obstetrical Management of the Older Gravida

Maximilian B Franz; Peter W Husslein

Disclosures

Women's Health. 2010;6(3):463-468. 

In This Article

Abstract and Introduction

Abstract

In developed countries, an increase in the average age of the gravida has been documented. The mean age of primiparous women in Austria rose from 25 years in 1991 to 28 years in 2008. In Germany in 2006, most gravidas were between the ages of 30 and 34 years whereas in the 1970s, most babies were born to women aged 20–24 years. Delayed childbearing and increased maternal age are associated with increased obstetrical and perinatal complications and, therefore, require adjustments in obstetrical management. Increasing maternal age is associated with pre-existing maternal risk factors such as diabetes mellitus, hypertension, myomas or obesity. In addition to lower fecundability and higher rates of chromosomal aberrations, higher rates of spontaneous early abortion are also common complications in early pregnancy among older women. In ongoing pregnancies, complications such as gestational diabetes, hypertensive disorders and low birth weight are associated with increasing maternal age. Furthermore, gravidas of advanced age are at a higher risk for stillbirth and perinatal morbidity and mortality. At delivery, increased maternal age is associated with an increased rate of malpresentation and represents an independent odds ratio for cesarean section. Owing to these facts, obstetric management in the older gravida needs to be adapted in order to manage the possible complications.

Introduction

In developed countries, a steady increase in the age of the gravida is evident and this is due to economic, educational and social factors. In one study, 152 patients aged 35 years or older who were seeking assisted reproductive technology for their first planned pregnancies were asked about their reasons for delaying childbearing.[1] The most commonly reported reasons were not having a partner (50%) and wanting financial security (32%) or a career (19%) before having a family. According to this study, 18% of the women were not aware of the impact of age on fertility. In Germany in the 1970s, most babies were born to mothers aged 20–24 years; however, in 2006, most babies in Germany were born to 30–34-year-old women.[2] According to Montan, the mean maternal age of primiparous women in Sweden was 24 years in 1973; this rose to 28 years of age in 2003.[3] Furthermore, the percentage of primiparous women aged 35 years or older rose from 2% in 1973 to 19% in 2003. In Austria, the mean maternal age of primiparous rose from 25 to 28 years between 1991 and 2008.[101]

Furthermore, advancing age results in a decrease in fecundability. Therefore, the use of reproductive medicine increases in older women. However, reproductive medicine itself might be one reason as to why more and more women are delaying childbearing and hoping for late babies with help of reproductive medicine.

Although some patients are aware of the risk of lower fecundability and may even be aware of elevated rates of chromosomal aberrations or higher abortion rates associated with increasing age, the risks that occur with pregnancy in the older gravida are often unknown by patients.[4] Preconceptional counseling and education regarding this aspect might need some more attention in the future in order to inform younger women about the possible consequences of delaying childbearing before they make the decision whether or not to do so.

New risks occur with perimenopausal women becoming pregnant after the use of artificial reproductive medicine and ovum donation; however, these issues are manifold and are therefore outside of the scope of this review.

The risks for older gravidas are discussed differently in the literature and this article will give an overview by discussing the risks occurring with advanced maternal age during the different stages of pregnancy and delivery. Furthermore, proposals for the management of these risks will be discussed.

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