|Year : 2019 | Volume
| Issue : 1 | Page : 1-2
Elderly parturients: A rising trend
Consultant Anaesthesia and Critical Care Department, Pratiksha Hospital, Guwahati, Assam, India
|Date of Web Publication||11-Apr-2019|
Dr. Daisy Gogoi
Consultant Anaesthesia and Critical Care Department, Pratiksha Hospital, Guwahati, Assam
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gogoi D. Elderly parturients: A rising trend. J Obstet Anaesth Crit Care 2019;9:1-2
The health of a mother lays a strong foundation to the health of the nation. During the past several decades, there is a remarkable shift in demographic changes in childbearing age worldwide. There is an increasing trend to delay childbearing beyond 40 years. The reason for this development is mainly due to the enormous changes in work culture, higher level of female employment and educational attainment of women, increasing use of reproductive techniques, and advancement ofin vitro fertilization (IVF) techniques. These social trends combined with effective birth control and greater range of treatment for infertility have resulted in a steadily expanding population of women who become pregnant after 35 years.
In the United States, birth rate of women 35–39 years was 51.0 per 1000 women in 2014, up by 3% from 2013. In Japan, it elevated from 8.6% in 1990 to 25.9% in 2012, and in China from 8.65% in 2004 to 17.04% in 2014. This accelerating demographic shift is of major clinical and public health concern because advanced maternal age (AMA) has been associated with adverse pregnancy outcomes.
In India, a prospective observational study consisting of 1263 women >35 years of age done at Jehangir Hospital, Pune, during a period of 2 years, found significantly high rate of miscarriages and ectopic pregnancy in women age 35 years and above, that is, 18.9% versus 10.6% and postpartum hemorrhage (PPH) 7% versus 2.5% in women age >35 and <35 years, respectively. Intrapartum and postpartum complications were higher in women age 35 years and above (35.2% compared with 25.5%).
In obstetric practice, maternal age is an important determinant of pregnancy, and both extremes of age are known to be associated with adverse maternal and fetal outcome. Elderly pregnancy leads to complication during pregnancy, labor, and also for the new born. AMA is generally defined as pregnancy in women age greater than 35 years.
In the United kingdom, a population-based cohort study consisting of 215,344 birth in women ≥40 years at delivery reported high risk of adverse maternal and perinatal outcomes such as PPH, eclampsia, cephalopelvic disproportion, and adverse infant outcomes including preterm birth, poor fetal growth, low birth weight, and neonatal mortality; there is also an increased risk of fetal death from intrapartum asphyxia at term. The various consequences of AMA are reduction in fertility rate, increased number of miscarriages, and increased number of fetuses with chromosomal anomalies (increased risk of trisomy 21); there is also an increase in congenital malformation. The rate of congenital heart diseases' defect is three to four times higher in women >40 years of age. Diaphragmatic hernia and club foot are also common in the new born. There is an increased risk of pregnancy complication such as obesity and diabetes mellitus, due to reduction in insulin sensitivity, and more lipid dysfunction and increase in blood pressure (BP). There is three times increase in the gestational hypertension in AMA as microvascular endothelial dysfunction is the basic pathology in preeclampsia which accelerates with advanced age. There is three times more risk of prematurity, one to four times higher risk of fetal death in utero, five times more likely of developing preeclampsia, and three times greater risk of placenta previa in patients with advanced maternal age. Vascular dysfunction is said to be the cause for placenta previa. PPH is more common due to the reduced number of oxytocin receptors and the incompetent capability of contraction of the aging myometrium. Pregnancy-related venous thromboembolism (VTE) rate is also high in elderly parturients. Hormonal-related decreasing venous capacitance and venous outflow are presumed to be responsible for the increased risk of thrombosis in pregnancy.
In 2009, World Health Organization (WHO) developed a standard definition for maternal near miss (MNM), maternal death (MD), and severe maternal outcome (SMO) based on the markers of organ dysfunction. MNM is defined as a women when nearly died but survived a complication that occurred during pregnancy, childbirth, or in 42 days of termination of pregnancy.
SMO is defined as women having had an MD or an MNM up to 7 days after giving birth or having an abortion, irrespective of gestational age or delivery status. In 2010–2012, multicountry survey on maternal and new born health (WHO MCS) data showed association between AMA and severe maternal and perinatal outcome. There is increased trend of fetal and perinatal anomalies such as preterm birth, low birth weight, and APGAR score <7. Rate of stillbirth and perinatal mortality per 1000 total birth were 19 and 27 in women age 20–34 years and up to 43 and 53 in women >45 years of age, respectively.
The elderly parturients have greater risk of obstetrical complications such as preeclampsia, and there is a need for magnesium sulfate therapy. Elderly parturients have higher risk for PPH and blood products transfusion. Elderly parturients need special attention during perioperative period; along with routine investigation, special emphasis should be given to the cardiovascular system. Echocardiography is generally needed preoperatively to view the cardiac status. Screening of coagulation is also needed preoperatively, as most of the patients who were treated for infertility undergoing IVF treatment used to be on anticoagulants like aspirin or low-molecular-weight heparin. The use of antihypertensive drugs and antidiabetic drugs should be monitored preoperatively. Intraoperative judicious fluid management, maintaining hemodynamic stability, airway manipulation, and timely intervention with uterotonics are needed for prevention of PPH in elderly parturients. Contributors of PPH include higher rate of preterm birth and higher rate of primiparity, as well as possible higher rate of placenta previa. The use of magnesium sulfate therapy is known to increase the propensity for PPH due to uterine atony. This is important from anesthetic point of view as there is a need for earlier insertion of large bore intravenous lines, earlier administration of antifibrinolytic agents such as tranexemic acid, and earlier performance of hemostatic tests. However, no significant changes are seen for analgesia for labor, epidural analgesia with regard to needle depth, number of punctures needed to establish epidural block, or any difficulty in insertion in elderly parturients. Postoperatively, patients need to be shifted to THE intensive care unit (ICU)/high dependency unit (HDU) for proper monitoring like prevention of VTE, fluid monitoring, blood transfusion, BP, and blood sugar monitoring.
In conclusion, the overall prevalence of AMA in a large multicountry analysis was 12.3% ranging from 2.8% in Nepal to 31.1% in Japan. AMA significantly increases the risk of MNM, MD, and SMO. It also increases the risk of preterm birth fetal mortality, low birth weight, and birth asphyxia, hence an increased need of neonatal intensive care unit admission. Facilities such as availability of blood bank, adult ICU, or HDU for adverse maternal outcome are also needed. Therefore, international and national maternal health policies should focus on advanced maternal age pregnancies.
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