Obstetrical Management of the Older Gravida

Maximilian B Franz; Peter W Husslein

Women's Health. 2010;6(3):463-468.

Stillbirth & Perinatal Mortality

Advanced maternal age is associated with an increased risk of stillbirth. In one of the largest studies to evaluate the influence of maternal age on stillbirth risk, Reddy et al. conducted an analysis of more than 5 million singleton deliveries. In this analysis, advanced maternal age was associated with a higher rate of stillbirth, with a peak risk period for stillbirth occurring among older mothers between 37 and 41 weeks of gestation.^[22]

Smith and Fretts presented data from a literature search. They presented an OR for stillbirth of 1.8–2.2 for women between 35 and 39 years of age and an OR of 1.8–3.3 for women over 40 years of age. Other epidemiological risk factors were nulliparity (OR: 1.2–1,4), smoking (OR: 1.7–3.0), obesity (BMI ≥30; OR: 2.1–2.8), having had a previous SGA infant (OR: 2.0–4.6), multiple gestations compared with singleton gestations and black compared with white race (OR: 2.0–2.2).^[23]

A total of 6,239,399 singleton pregnancies in the USA were analyzed by Bahtiyar et al. in order to evaluate the influence of advancing maternal age on stillbirth.^[24] The ORs were referred to the group of 25–29-year-old mothers who had the lowest stillbirth risk. When compared with this group, the odds of stillbirth at term increased significantly with advancing maternal age (OR for mothers aged 30–34 years: 1.24; OR for mothers aged 35–39 years: 1,45; and OR for mothers aged 40–45 years: 3.04).

Interestingly, the risk of stillbirth for women aged 40–44 years at 39 weeks of gestation is comparable with women aged 25–29 years at 42 gestational weeks.

Therefore, the authors concluded that a strategy of antenatal testing beginning at 38 gestational weeks for women over the age of 40 years may be considered. According to the authors, delivery by 39 weeks may also be considered for women over 40 years of age since the cumulative risk of stillbirth in women aged 40–44 years at 39 weeks is nearly identical to the risk in those aged 25–29 years at 42 weeks.

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Abstract and Introduction
Early Pregnancy
Ongoing Pregnancy after 20 Gestational Weeks
Delivery
Stillbirth & Perinatal Mortality
Future Perspective
References
Sidebar

Sidebar

Executive Summary

Background

The mean age of women at delivery is rising in developed countries.
Many women are not aware of the consequences of delaying childbearing.
With advancing age, fertility and fecundity decrease.

Early pregnancy

With increasing age, the risk of miscarriage increases.
Women aged over 45 years have a 90% risk of miscarriage.
The association between maternal age and chromosomal aberrations, and malformations without chromosomal aberrations, is well known.

Increased risks in pregnancies at advanced maternal age

The risk of hypertensive disorders in pregnancy increases with advanced age.
- No valid screening method is currently available besides the anamnesis of medical and family history.
With advanced age, the risk of pre-existing diabetes increases.
The risk of gestational diabetes.
- An oral glucose tolerance test should be carried out in all parturients, at least in those with maternal ages of 35 years or over.
Obesity increases with advanced age.
With advanced age, the risk of small-for-gestational-age infants increases.
The risk of preterm delivery increases with advanced age.
With advanced age, the risk of placenta previa increases.
- The exact localization of the placenta should be examined at the second trimester screening.

Delivery

Cesarean delivery rates increase with advanced maternal age.
Vaginal operative delivery rates increase with advanced maternal age.
If the maternal age distribution had stayed at the level that it was in 1980, 38% of these additional cesarean deliveries would have been avoided.
With increasing maternal age, spontaneous activity of the uterine smooth muscle is reduced and multiphasic spontaneous myometrial contractions increase.
Therefore, the association between increasing maternal age and the risk of intrapartum cesarean delivery could have a biological basis.

Stillbirth

Advanced maternal age is associated with an increased risk of stillbirth.
The risk of stillbirth for women aged between 40 and 44 years of age at 39 weeks of gestation is comparable with that of women aged 25–29 years at 42 gestational weeks.
Therefore, a strategy of antenatal testing beginning at 38 gestational weeks for women over the age of 40 years may be considered.
Delivery by 39 weeks may also be considered for women over 40 years of age as the cumulative risk of stillbirth in women of 40–44 years of age at 39 weeks is nearly identical to the risk in those of 25–29 years of age at 42 gestational weeks.

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