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It has been made on the basis of article „Pregnancy and delivery in older age” written by Petronella Hupuczi, published in bulletin No.1. of 2012 of the Gynecology and Obstetrics Postgraduate Review (edited by Zoltán Papp)

 If the pregnant mother is over 35 years

Obstetric practice of the past decades has undergone important changes. Most of these changes can be attributed to the propagation and development of the assisted reproduction methods. Of course social changes also contributed to this, as well as the fact that the first child has been undertaken one decade later at the average. Due to the approval of women’ career, muddling of the gender roles and later marriages and relationships it is not rare today that couples get a child in their 4th-5th decades. Conception can cause difficulties in this age from several aspects. Fertility begins reducing at the beginning of the thirties and the change of getting pregnant reduces by 3-5 % each year. Really dramatic drop can be observed after the forties. Women abort with the probability of 12-15 % in their twenties, and this rate reaches 50 % over 40.

This can be observed both in case of assisted reproduction and in natural conception. Anovulation cycles are frequent (cycle without follicle development) and early ovary exhaust is a determinant factor. In these cases the methods of assisted reproduction should be used. In course of IVF program conception is about 45 % under 40 years but it is only 15 % over 40. Considering the rate of children taken home, the situation is even more sadder; it is 40 % in the younger age group and only 5-7 % in case of the older women. Reducing success during the different infertility treatments can be explained with deteriorating quality of the ovum. Necessity of ovum donation is increasing exponentially above 40 years, while this rate is 5 % under 35 years; it is 77 % over 45 years. Chromosomal abnormalities above 35 years mean an important risk factor, in particular the frequency of trisomies (conditions with overnumber chromosomes) is increasing.

It means that changes related to age have severe health consequences. Expectancy undertaken in older age means higher risk both for the mother and the fetus

Very advanced age of the mother

Professional literature reckons older („advanced”) maternal age from the age of 35. There has been introduced a new definition in the recent years, which refers to very advanced age, over 45 years.

Willingness to undertake a baby has tripled from the 1960ies to now in case of women over 30 years, namely it increased from 8.6 % to 25.4 %. This increase is six fold over 35 years (from 1.3 % to 8.3 %) and 15-fold over 45 years (from 0.1 % to 1.5 %).

Increasing age of the mother can also be observed in Europe, especially in West- and South Europe. The rate of women giving birth over 35 years is considerably higher in Poland, too (11 %) The rate of women undertaking a child in such an old age is the highest (18 %) right in the two South European countries: Spain and Italy showing the lowest fertility rate, but it accounts for 15-17 % in Sweden, the Netherlands and Switzerland, too.

According to the data of Tárki the rate of new mothers over thirty had increased from 18 to 29 percent between 1990 and 2000. In the past one and a half decade the average age of the mothers has increased by 4,3 years; it was 37,4 years in case of women delivering their first child in 2008 and the ladies who have graduated from the university delivered their first child around 30 years. The average mothers’ age is similar in the other countries of Middle- and East Europe, too. On the contrary the average age of delivering women is 30 years in South Europe and 29 years in North and West Europe.

 

Increasing risks with advanced maternal age

Several publications deal today with the results of pregnancies undertaken in older age of the mother. According to a report published in 2007 more than 8 million of live births were investigated in the range of women who delivered between 30 and 54. The results shown that the average birth weight was lower in the older age groups. The most frequently developing complications in case of women delivering over 45 years for the first time, as compared to the age group of 30-34 years is hypertension, diabetes and premature delivery before the 32nd week. Frequency of Caesarean section is much higher than in case of 30-34 years, both in the groups of primiparas and multiparas. The probability of important blood loss is half times more in the range of pregnants over 45. Defensive medical decisions because of the malpractice lawsuits, fear from traumatic effects of difficult vaginal delivery and of brain injury of the fetus, play important role, while prevention of possibly developing complaints from decensus after vaginal delivery play less important part in the extremely high rate of Caesarean sections.

The data of 131 prima gravidas over 45 years have been processed in another study. Age of the expectant women is between 45 and 65, their average was 48.3 year. 31.2 % of the cases pregnancy developed with chronic maternal disease, e.g. chronic hypertenstion, hypothyiroidism, diabetes, hematopoietic and cardiologic diseases. 93.9 % of the pregnancies was finished with Caesareian section. Each woman over 50 years gave birth with Caesarean section. The average birth weight was 2592 gr. The low birth weight occurred in 68.5 % of the women over 50 years, contrary to 34.9 % of women between 45 and 49 years.

In the third series of investigation 5487 pregnant women were followed, with special regard to the fate of pregnancies in very old age. It was found that chronic maternal diseases and praeeclampsia („toxic” disease with hypertension, and proteinuria) occur more frequently over 45 years than in the younger age groups. Delivery management was Caesarean section in the majority of the cases (78.5 %), but at the same time severe bleeding, fiver and blood transfusion were more frequent after delivery. Indications of Caesarean section included operation at the request of the mother, preliminary Caesarean section, placenta implantation abnormalities, breech and premature delivery. Due to the above longer hospital care was necessary. Because of the higher rate of premature delivery hospitalization at the neonatal intensive department was more frequent, too (10.7 %). Of course the result of pregnancies over 50 years was the worst.

 

Összefoglalás

The rate of pregnancies undertaken in older ages (especially over 45 years) makes only a small part as compared to total live births. However their number has significantly increased in the past decades, especially thanks to the possibility of ovum donation and continuous development of the assisted reproduction methods. The reason of higher health risk of pregnancies in older age of the mother is that chronic diseases have already manifested themselves in this age, heart and vascular loadability is reduced, as well as, the capability of adaptation to the changes caused by pregnancy is also lower. Further ordeal for the couples is that the number of chromosomal abnormalities is also higher than it is among women younger than 30. Prior to pregnancies undertaken in old age the couple must be given detailed information about the possible mother’s and fetal risks. Amniocentesis (sampling of amniotic fluid through abdominal wall of the mother) and embryonic chromosome analysis from the amniotic fluid cells is usually necessary.

 Care for expectancy itself is the task of obstetric departments which have appropriate experience in complex care of such patients, since wider diagnostic processes may become necessary in these cases. Hospitalization must be accounted for more often and the probability of Caesarean section is also higher.

Of course not only the difficulties but also the benefits of pregnancies undertaken in very old ages must be considered. These are more consciously undertaken pregnancies than the average, and the children are born in an environment where financial safety is waiting for them and they are surrounded with greater attention.

Maternity Obstetric and Gynecological Private Deparment is prepared for care of pregnancies of women of advanced ages and for management of their delivery.

Dr. Petronella Hupuczi

Dr. Petronella Hupuczi
Head of the anesthesiology service.

 

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