There is currently an increasing trend towards delay childbearing across the world. Among the reasons are delay due to longer schooling, late marriage, shift in life priority, financial security, availability of contraception and women exercising their choices. The consequence of this shift has led to more elderly pregnant mothers.
The commonly accepted definition of advanced maternal age (elderly) is 35 years or more. Studies have shown that pregnancy in this group of women is associated with a higher complication risk to both the mother and baby. Women should be supported in their decisions of whether to have children or not and when to plan childbearing. They should also be aware that the fertility and pregnancy outcomes change with age. For these reasons, women are encouraged to consider having families during the period of optimum fertility.
Pregnancy risks
Maternal age has been shown to affect pregnancy from conception to delivery. Biologically, the best period for pregnancy is between 20–35 years of age. The spontaneous conception rate is 75% in women aged 30 compared to 66% in those aged 35 years old (Leridon 2004). The pregnancy rate in elderly women is lower due to poorer egg quality associated with aging. There is also a higher risk of spontaneous miscarriage. The reported miscarriage rate at 22 years old is 8.2%, but increases to 20% among women at 35 years of age.
Elderly mother has an increased risk of fetal chromosomal abnormalities and congenital anomalies. The risk of Down syndrome, the commonest cause of mental retardation is significantly increased from 1 in 1000 when the pregnant woman is 25 years of age compared to 1 in 250 at 35 years.
There is also a higher association of preterm birth, small for gestational age (small baby and intrauterine growth restriction, IUGR) among elderly mothers. The preterm delivery may be unexplained or iatrogenic, due to intervention following maternal complications (see below). Elderly mother may be associated with poorer placental perfusion or transplacental flux of nutrients. This led to an increased likelihood of a small for gestational age baby. All these complications are associated with a higher neonatal intensive care unit admission and higher morbidity.
Increase perinatal morbidity and mortality
The risk of stillbirth (fetal demise after 28weeks gestation) is significantly higher in older women, partly due to the risks of aneuploidy (chromosomal anomalies) and fatal congenital anomalies. The increased incidence of small for gestational age babies in the older women further contributes to the increased stillbirth rate.
Maternal complications
Older women are more likely to have pre-existing medical disorders such as diabetes mellitus or hypertension, which further complicate the pregnancy. There is an increased incidence of antepartum haemorrhage, malpresentation, pre-eclampsia and gestational diabetes mellitus. All these complications lead to a higher operative vaginal delivery and Caesarean section.
Conclusions
Pregnant women aged ≥35 years are at increased risk of complications in pregnancy compared with younger women. Although women should be supported in their life choices, they should be aware of the possible problems that older mothers may encounter. Adherent to frequent antenatal visits, under an experienced obstetrician and increased fetal surveillance are some measures that may help to ensure a better outcome.
References
- Huang L et al., CMAJ 2008.
- Leridon H. Human Reproduction 2004
- RCOG statement on later maternity age 2009
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