Obstetrical Management of the Older Gravida

Maximilian B Franz; Peter W Husslein


Women's Health. 2010;6(3):463-468. 

In This Article

Ongoing Pregnancy after 20 Gestational Weeks

Obesity, pre-existing diabetes, pre-existing hypertension and multiple pregnancies, among others, are known risk factors for hypertensive disorders in pregnancy including all various forms of preeclampsia.[7] All these factors occur more commonly with advancing maternal age.[8] Furthermore, maternal age is an independent risk factor for preeclampsia itself. In a case–control study of 468 pregnant women aged 40 years or older, a risk of 6.6% for preeclampsia was demonstrated compared with a risk of 3.9% in patients aged 20–29 years (p < 0.01).[9] These findings reflect the findings from a number of other studies[8,10,11] that identify advanced maternal age as a risk factor for hypertensive disorders in pregnancy and preeclampsia. Therefore, the advanced age gravidas should be screened carefully for possible risk factors for hypertensive disorders in pregnancy. To date, the only routinely used method to evaluate the risk of preeclampsia, besides an accurate anamnesis of family and medical history, is Doppler sonography of the uterine arteries. Nevertheless, this method, as a single test, is not a valid screening method and is therefore not used in many centers. A number of biochemical agents have been assessed as markers for predicting preeclampsia. Until now, none have been used in the clinical routine. However, some promising markers have been identified, such as placenta protein 13 (PP-13), soluble fms-like tyrosine kinase-1 (sFLT-1) and soluble endogline, which might allow screening at a relatively early stage of pregnancy. When combined with Doppler sonography, these markers demonstrate relatively high predictive values.[7] Further large studies to evaluate these biochemical markers are needed; however, advanced age gravidas should be one of the first groups in which these screening methods are implemented.

Obesity has become one of the most serious problems for all healthcare systems in the western world, and, as mentioned previously, the rate of obesity is increasing with age. Salihu et al. demonstrated the prevalence of obesity (BMI ≥30) to be 11.3% in pregnant women at 20–24 years of age rising slightly with advancing age up to 18.6% for gravidas of over 40 years of age.[7] As reported by Robinson et al. from a Canadian cohort study, in 1988, 3.2% of pregnant women were obese compared with 10.2% in 2002.[12] In this study, it was shown that moderately obese women were at a 2.38-fold higher risk for hypertensive disorders in pregnancy, a 2.17-fold higher risk for venous thromboembolism in pregnancy, a 1.94-fold higher risk for labor induction, a 1.6-fold higher risk for cesarean section and a 1.67-fold higher risk for consecutive wound infection. Furthermore, severely obese women had a 2.01-fold increased risk for anesthesia complications. Owing to these facts, obese women of any age should be counseled regarding their risks from a possible pregnancy before conception.

The prevalence of insulin-dependent diabetes and other forms of diabetes, including gestational diabetes, increases significantly with advancing maternal age.[3,8,9] The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study demonstrated that with increasing maternal glucose levels, the frequencies of birth weights above the 90th percentile, undergoing primary cesarean section, clinical neonatal hypoglycemia and cord-blood serum C-peptide being greater than the 90th percentile were increased.[13] Furthermore, it was shown that with increasing glucose levels, the risks for preeclampsia, shoulder dystocia or birth injury increased. Regarding these results, ideally, a 75-g glucose tolerance test should be carried out in all gravidas, but owing to the fact that older gravidas are at a higher risk for gestational diabetes, this test should be mandatory for gravidas older than 35 years of age. Nevertheless, there is continuing debate as to whether all pregnant women should be screened or whether to restrict screening to women with risk factors since risk-based screening could overlook up to 50% of cases of gestational diabetes.

The data for preterm delivery and small-for-gestational-age (SGA) infants in pregnant women of advanced age remain the subject of discussion. A cohort study from 1990 that evaluated data from 3917 patients aged 20 years or older demonstrated no evidence that women aged 30–34 years or women aged over 35 years have an increased risk for preterm delivery or SGA infants.[14] In contrast to this, later studies demonstrated that advanced maternal age is associated with preterm delivery. A study of 24,032 gravidas aged 40 years or older demonstrated significantly higher rates of SGA births in older nulliparous and multiparous women compared with nulliparous and multiparous women of 20–29 years of age.[15] The rate of SGA infants in older multiparous women was 2.5% compared with 1.4% in the younger control group. For older multiparous women, the rate of SGA births was 1.4% compared with 1.0% in the younger control group. The mean birth weight of infants delivered by older nulliparous women was significantly lower (3201 ± 10 g) compared with the younger control group (3317 ± 1 g), whereas in multiparous women, there was no significant difference between older and younger mothers (3381 ± 5 g and 3387 ± 1 g, respectively). In older nulliparous and multiparous women, gestational age at delivery was significantly lower than in the younger control groups. Nevertheless, it remains unclear whether advanced maternal age is an independent risk factor for preterm delivery and SGA infants or whether risk factors that occur more frequently with advanced maternal age lead to these results.[16]

A study of 123,941 pregnancies between 1980 and 1993 evaluated the risk of uteroplacental bleeding disorders in pregnancy in relation to advanced maternal age.[17] The risks of placental abruption, placenta previa and uterine bleeding of unknown etiology were examined. The frequencies of placental abruption and uterine bleeding of unknown etiology showed no increase with advancing maternal age. The risks of placental abruption and placenta previa were associated with higher partity among younger women but not with advanced maternal age. However, it was demonstrated that the risk of placenta previa dramatically increased with advanced maternal age. In this cohort, gravidas older than 40 years of age had a nearly ninefold greater risk for placenta previa than women under the age of 20 years. These data were confirmed by Ziadeh and Yahaya; however, in this study of 468 patients aged 40 years or older, antepartum vaginal bleeding also occurred more frequently in the older group compared with gravidas of 20–29 years of age.[9]

Therefore, in our opinion, all gravidas, irrespective of their age, should have an accurate examination of the location of the placenta conducted in the second trimester, as detection of placenta previa would change the required management and the recommendation towards having an (earlier) elective cesarean delivery.


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