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Reproductive Medicine
International Journal
Journal of
of Reproductive
Medicine
Volume
2013, Article
Volume 2013,
Article ID
ID 287519,
287519, 44 pages
pages
http://dx.doi.org/10.1155/2013/287519
http://dx.doi.org/10.1155/2013/287519

Research Article
Pregnancy Outcome of Multiparous Women Aged over 40 Years
Seda Ates,1, 2 Gonca Batmaz,1 Osman Sevket,1 Taner Molla,1 Cem Dane,3 and Banu Dane1
1

Department of Obstetrics and Gynecology, Bezmialem Vakif University, 34093 Istanbul, Turkey
Bezmialem Vakif University, Adnan Menderes Bul. Vatan Cad., 34093 Istanbul, Turkey
3
Department of Obstetrics and Gynecology, Haseki Education and Research Hospital, Istanbul, Turkey
2

Correspondence should be addressed to Seda Ates; drsedaates@yahoo.com

Received 18 November 2012; Revised 17 December 2012; Accepted 19 December 2012
Academic Editor: Yves Jacquemyn
Copyright 2013 Seda Ates et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. e aim of this study was to evaluate the eect of maternal age on prenatal and obstetric outcome in multiparaous women.
Materials and Methods. A retrospective case control study was conducted, including women aged 40 years and over (study group,
) who delivered at 20 weeks gestation or beyond and women aged 2029 years (control group, ). Results. e mean age
of women in the study group was 41.2 1.7 years versus 25.4 2.3 years in the control group. Advanced maternal age was associated
with a signicantly higher rate of hypertension, diabetes mellitus, fetal complication, and 5-minute Apgar scores <7 ( ).
Caeserean section rate, incidence of placental abruption, preterm delivery, and neonatal intensive care unit admission were more
common in the older group, but the dierences were not statistically signicant. Conclusions. Advanced maternal age is related to
maternal and neonatal complications.

1. Introduction
Many women increasingly delay pregnancy and childbirth
into their fourth decade of life because of dierent reasons,
such as delay in marriage, educational and professional
reasons [1]. Some of them experience pregnancy unwillingly
because of inappropriate use of contraceptive methods [2].
Advanced maternal age has been regarded as a risk factor
for complications in pregnancy. e association between
advanced maternal age and increased risk of chromosomal
abnormalities and spontaneous abortion has been well documented in studies [3, 4].
ere are dierent publications in the literature on
pregnancy outcomes of women aged 40 years or older. Some
authors have reported that advanced maternal age has been
associated with preterm delivery, low birth weight, perinatal
mortality, and higher frequency of cesarean section [5, 6]. But
others have reported no obvious dierence in the perinatal
outcomes [7], obstetric outcomes [8], birth weight, Apgar
score, and admission to neonatal intensive care unit [9]
between younger and older mothers. A systematic review
stated that advanced aged mothers have an increased risk of

stillbirth. e mechanism of the increase in stillbirth risk with

advanced maternal age is uncertain [10].
e aim of this study was to determine the eect of maternal age on obstetric and perinatal outcome in multiparous
women aged at least 40 year old with multiparous women
aged 2029 years.

2. Materials and Methods

is is a retrospective study for women delivered at gestational ages of >20 weeks in Bezmialem Vakif University and
Haseki Education and Research Hospital between October
2010 and December 2011. We reviewed the obstetric records
of 97 multiparous women aged 40 or above at the time of
delivery and compared with a control group which consisted
of consecutive 97 multiparous women with ages 2029 years
who delivered at the same period of time. e following
data, including maternal age at the time of delivery, gravidity,
parity, gestastional age, antenatal complications (pregnancyinduced hypertension, diabetes, preterm delivery, delivery
<24 weeks, abruptio placenta, small for gestational age,

2
large for gestational age), mode of delivery, indications for
ceaserean sections, intrapartum, and neonatal outcome (fetal
distress, fetal complication, fetal malformation, birth weight,
Apgar score, neonatal intensive care unit admission, and
stillbirth) were collected and compared with a control group.
Maternal age was considered as the age at the time of
delivery. Gestational age was determined on the basis of
either date of last menstrual period or ultrasound examination. Diastolic blood pressure >90 mmHg was dened as
hypertension in pregnancy (essential or pregnancy-induced
hypertension). Diabetes mellitus was considered as history
of diabetes (based on medical records) or gestational diabetes. Like other studies, we combined chronic hypertension,
pregnancy-induced hypertension, and eclampsia into one
condition called HDP (hypertensive disorders of pregnancy),
and we combined gestational and established diabetes into
another [11].
Abruptio placentae refers to the premature separation of
the normally implanted placenta from the uterus. Preterm
birth was dened delivery before 37 completed gestastional
weeks. Small for gestational age (SGA) was dened as <10th
percentile of birth weight for gestational age and large for
gestational age (LGA) as 90th percentile. Stillbirth was
dened as intrauterine death of a fetus weighing at least 500 g
aer 20 completed weeks of gestation. Low Apgar score was
dened as a score of less than seven at 5 min following birth.
Fetal complications include stillbirth, neonatal intensive care
unit admission, and fetal malformation.
Statistical analysis was performed using the MedCalc for
Windows, version 8.1.00 (MedCalc Soware, Mariakerke,
Belgium). Data were presented as means standard deviations or numbers of subjects and percent. Chi-square and
Fishers exact test were used to compare the variables. Odds
ratio (OR) and 95% condence intervals (CI) are presented in
order to analyse the risk related with advanced maternal age,
and was regarded as statistically signicant.

3. Results

We reviewed 97 records of women aged 40 years old or more.

e mean age of women in the study group was 41.21.7 years
and that in the control group was 25.4 2.3 years at the time
of delivery. e older mothers had a higher mean gravidity
compared with for the control group (4.9 2.5 versus 2.6 1,
). Gestational age at the delivery was lower among
the older mothers compared with the younger women (Table
1).
e incidence of hypertension and diabetes mellitus was
signicantly higher in older women compared with the
younger group. Abruptio placenta, delivery before 24 weeks,
preterm delivery, and LGA were seen more oen among
older mothers but the dierence did not reach the level of
signicance (Table 2).
e infants of the older mothers showed a higher
incidence of stillbirth (5.1% versus 0%), admission to the
neonatal intensive care unit (5.1% versus 1.03%), and fetal
malformation (3.09% versus 0.8%) than younger mothers,
but the dierences were not statistically signicant. e

International Journal of Reproductive Medicine

T 1: Patients characteristics.

Age (years)
Gravidity
Gestational age (weeks)

Value are mean SD.

Study
group
(: 97)

Control
group
(: 97)

41.2 1.7
4.9 2.5
37.8 3.2

25.4 2.3
2.6 1
38.6 1.7

value

<0.0001
<0.0001
0.03

T 2: Antenatal complications.

Hypertension
Diabetes mellitus
Abruptio placenta
Delivery <24 weeks
Preterm delivery
SGA
LGA

Study
group
(: 97)

Control
group
(: 97)

12 (12.3)
8 (8.2)
3 (3.09)
2 (2.06)
15 (15.4)
7 (7.2)
13 (13.4)

2 (2.06)
0 (0)
0 (0)
0 (0)
10 (10.3)
11 (11.3)
9 (9.27)

value
0.01
0.01
0.24
0.47
0.39
0.46
0.49

PIH: Pregnancy-induced hypertension, SGA: Small for gestational age, LGA:

Large for gestational age.
Data are presented (%) Chi-square, Fishers exact test.

T 3: Fetal and neonatal outcome.

Stillbirth
NICU
Fetal malformation
Fetal complication
Fetal weight (gram)
5-minute Apgar score <7

Study
group
(: 97)

Control
group
(: 97)

5 (5.1)
5 (5.1)
3 (3.09)
12 (12.3)
3190 819
8 (8.2)

0 (0)
1 (1.03)
1 (0.8)
2 (2.6)
3264 487
1 (0.8)

value
0.07
0.21
0.52
0.021
0.44
0.032

Value are mean SD.

Data are presented (%), NICU: neonatal intensive care unit (1 Down S., 1
mega cysterna manga, 1 NTD, 1 fetal ascites.

results showed that the rate of fetal complication ( ),

5-minute Apgar scores <7 ( ) were signicantly
higher among older mothers (Table 3).
e cesarean section delivery rate was 65.9% in the study
group and 55.6% in the control group, respectively. e
repeat cesarean sections in both groups were performed aer
the onset of labour, no programmed section was performed
in any of the groups. e major indication for cesarean
delivery in this study included previous cesarean section in
both groups.
e incidence of cesarean section for fetal distress (
0.017) and fetal macrosomia ( ) was signicantly
higher in the group of older mothers than in the younger
mothers (Table 4).
e risk of hypertension (OR, 6.7; 95% CI, 1.4530.8;
), diabetes mellitus (OR, 18.5; 95% CI, 1.05-325;

International Journal of Reproductive Medicine

), and 5 minute Apgar score <7 (OR, 8.62; 95% CI,

1.0570.3; ) were higher among the older group.
e rate of cesarean delivery was higher in older group (OR,
1.54; 95% CI, 0.862.7; ) but the dierence was not
statistically signicant (Table 5).

Indication

Study
group
( : 64)

Control
group
( : 54)

Previous cesarean section

32 (50)

49 (90.7)

Fetal distress

4. Discussion

13 (20)

2 (3.7)

Peeclampsia

6 (9.3)

2 (3.7)

Our study conrms a signicant higher incidence of hypertension and diabetes mellitus among pregnant women age 40
and older, which has been reported in other studies [1214].
e prevalence of diabetes and hypertension are increased
by age and considered to induce vascular endothelial damage
that occurs with aging [15].
Contrary to the literature [12, 16, 17], the cesarean section
was slightly higher in the older multiparous mothers aged 40
and older compared with younger multiparous mothers in
our study. Many reports have described a higher incidence
of cesarean delivery among the nulliparous women age 40
or older [5, 18]. Elderly primiparous women frequently
have a long history of infertility and the probability of
this being the only pregnancy may inuence a physicians
decisions to perform caesarean delivery. is suggested that
parity imposed a more important eect on the incidence
of cesarean section than maternal age. In this study, the
incidence of placental abruption was higher in women aged
40 years or older than younger women, this dierence was
not signicant.
e primary indication for cesarean section in this study
was previous caesarean delivery in both groups. e main
reason for the high caesarean section rates in the control
group (90.7%) is related to the previous caesarean deliveries.
Caesarean section rates are increasing recently in many
countries [19]. e caesarean section rates in these young
women who had previous caesarean sections is high since
the indications of caesarean section is also increased in
our country. e women in the study group are older and
thus they may not be as aected as the younger control
group from this rise in the changing trend of the delivery
route. Additionally, the high rate of cesarean delivery in both
groups is due to the fact that our clinic is a tertiary center.
Fetal distress constituted 20 and 3.7% of the indications for
caesarean section in older and younger mothers, respectively.
e rate of cesarean section for fetal macrosomia is accounted
for 12.5% in the study group and 1.03% in the control group.
is signicantly higher rate of cesarean section may be
related with diabetes mellitus which is clearly regarded as a
cause of macrosomia [20].
Mean gestational age for the older group at delivery was
signicantly lower than that for the younger group. is fact
may be associated with maternal or fetal problems such as
diabetes, chronic hypertension, and fetal distress [18] which
is more frequently seen in older mothers.
e rate of stillbirth was higher among the older group
although the dierence was not signicant. Stillbirth occured
in 5 cases in the study group in which down syndrome was
the reason of death in one case. e rest of the patients did
not accept the autopsy. e risks of aneuploidy and fatal

Malpresentation

2 (3.1)

1 (1.03)

0.89

T 4: Cesarean section indications.

value

<0.0001
0.017
0.4

Fetal macrosomy

8 (12.5)

1 (1.03)

0.041

Failure to progress

2 (3.1)

2 (3.7)

0.74

Previous myomectomy

1 (1.5)

0 (0)

0.9

Cord prolapse

1 (1.5)

0 (0)

0.9

Fetal anomaly

1 (1.5)

0 (0)

0.9

Data are presented (%). Some of the cases had more than 1 indication.

congenital anomalies increase with maternal age and, despite

antenatal screening, they are likely to have contributed to
the increased rate of stillbirth [21]. e failure of uterine
vasculature to adapt to the increased hemodynamic demands
of pregnancy has also been suggested as a cause of fetal
death in women aged 40 years and older [20]. is study
shows that a 5-minute Apgar score <7, which is a better
indicator of long-term neonatal outcome, was higher in the
older mothers compared with the younger ones. Additionally
the rates of stillbirth and fetal complication was higher in the
older group.
Neonatal intensive care unit admission was more frequent
among in the older women although the dierence was not
statistically signicant ( ). It may be explained by the
increased incidence of fetal distress, with lower Apgar scores
and fetal distress among older patients.
Advance maternal age was also a risk factor for preterm
delivery in our study. e rates of preterm delivery, delivery
<24 week were more frequently seen among in the older
mothers, although the dierence was not statistically significant. Maternal and fetal complications such as hypertensive
diseases, diabetes, and fetal distress may contribute to the
increased risk of preterm delivery among the multiparous
women aged 40 years and older [14].
Mean birth weight was almost the same for the two age
groups. erefore, this would suggest that maternal age may
not aect birth weight as much as other factors [4].
In conclusion, pregnancy in older multiparous women
seem to have higher rates of obstetric complications and
adverse birth outcomes, such as hypertension, diabetes, and
lower Apgar scores. Women should be informed that the
risk of pregnancy complications and adverse birth outcome
increases with age. Additional studies are needed to examine
the relationship between maternal age and maternal and fetal
outcomes and the mechanisms on how advanced maternal
age increases the risk of adverse birth outcomes in dierent
subgroups of women.

International Journal of Reproductive Medicine

T 5: Comparison of maternal and neonatal complications between women aged >40 years and those aged 2029 years.

Hypertension
Diabetes mellitus
Preterm delivery
Cesarean delivery
SGA
LGA
5 minute Apgar score <7
Intrauterine fetal death

Study group
(: 97)

Control group
(: 97)

OR
(95% CI)

12 (12.3)
8 (8.2)
15 (15.4)
64 (65.9)
7 (7.2)
13 (13.4)
8 (8.2)
5 (5.1)

2 (2.06)
0 (0)
10 (10.3)
54 (55.6)
11 (11.3)
9 (9.27)
1 (0.8)
0 (0)

6.7 (1.4530.8)
18.5 (1.05325)
1.59 (0.673.7)
1.54 (0.862.7)
0.60 (0.221.64)
1.51 (0.613.7)
8.62 (1.0570.3)
11.5 (0.63212.6)

value
0.014
0.046
0.28
0.14
0.32
0.36
0.044
0.09

Data are presented (%), OR: odds ratio, CI: condence interval.

Disclosure

e authors have no conict of interests to declare in relation

to this paper. e authors do not have a direct nancial
relation with the statistical soware that is mentioned in their
paper.

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