Obstetrical Management of the Older Gravida

Maximilian B Franz; Peter W Husslein

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

Future Perspective

Obstetric management of gravidas of advanced age will become more and more important. Owing to social development and reproductive medicine in the future, even more women will delay childbearing and become older mothers.

Advanced maternal age is associated with increasing risks during pregnancy and delivery. The increasing cesarean delivery rates in older gravidas are only partially caused by increasing gestational complications. Nevertheless, cesarean delivery rates will probably show a steady increase in the future, especially in mothers of advanced age.

With increasing numbers of women delaying childbearing, in many cases, pregnancy and delivery will become a single event in a mother's life, and therefore, will be of more importance to the families. Therefore, not only the quality of medical treatment but also the quality of support and service during pregnancy and delivery will become essential and might be a reason for increasing cesarean delivery rates. Where affordable, hotel-like delivery clinics with high medical standards for 'the one birth' of wealthy patients might become a concept for the future.

Between 10 and 15 years ago, women over 35 years of age were treated as being at high risk for pregnancies and gravidas aged over 40 were rare cases. In the future, the gravida aged over 40 years will probably become as common as the gravida aged over 35 years currently is. With modern obstetric management, most of the occurring complications can be managed successfuly. However, more counseling of younger women before delaying childbearing regarding their later risks of lower fertility and the higher pregnancy complication rates is needed.

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Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.

Cite this: Obstetrical Management of the Older Gravida - Medscape - May 01, 2010.

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

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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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