Perinatal outcomes of pregnancy in the fifth decade and beyond– a comparison of very advanced maternal age groups
A. SchwartzAriel ManyUdi ShapiraMichal Rosenberg FriedmanYariv YogevTomer AvnonSwati AgrawalShiri Shinar
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Abstract To study the effect of very advanced maternal age on perinatal outcomes. A retrospective cohort study of women aged 45 years and above, who delivered ≥22 weeks of gestation in a single tertiary center between 1/ 2011 and 12/ 2018. Maternal and neonatal outcomes were compared between women ≥50 years and women of 45–49 years at delivery. Of 83,661 parturients, 593 (0.7%) were 45–49 years old and 64 (0.07%) were ≥50 years old. Obstetrical characteristics were comparable, though the rate of chronic hypertension and preeclampsia with severe features were greater in women ≥50 years (6.2% vs 1.4%, p = 0.04, 15.6% vs 7.0%, p = 0.01, 95% CI 0.19–0.86, respectively). Elective cesarean deliveries were independently associated with advanced maternal age ≥50 (OR 2.63 95% CI 1.21–5.69). Neonatal outcomes were comparable for singletons, but rates of ventilatory support and composite severe neonatal outcomes were higher in twin pregnancies of women ≥50 years (42.8% vs 13.5%, p = 0.01, and 21.4% vs 4.0%, p = 0.03, respectively). Healthy women ≥50 have higher elective cesarean rates, despite similar maternal and neonatal characteristics.Keywords:
Advanced maternal age
Chronic hypertension
Chronic hypertension during pregnancy has recently shown a significant increase, which is most likely due to the growth in the number of first pregnancies in women of late reproductive age, with chronic hypertension, obesity and other extragenital diseases, as well as an increase in the number of pregnancies as a result of in vitro fertilization. Preeclampsia complicates chronic hypertension in 20-40% of cases, more often associated with early onset (before 34 weeks) and leads to an increase in complications in the mother, fetus and newborn. Currently, there are no reliable biomarkers that make it possible to predict the development of superimposed preeclampsia, but their search is underway. In the general obstetric population, the use of PlGF and sFlt-1 tests has shown to be promising for predicting preeclampsia in women with singleton pregnancies. PlGF and sFlt-1 based tests have begun to appear in clinical guidelines in addition to regular clinical and laboratory testing. But data on the effectiveness of these tests for predicting preeclampsia in groups of pregnant women with chronic diseases, including those with chronic hypertension, is still being collected. Purpose - to evaluate the prospects of using angiogenic factors as biomarkers of superimposed preeclampsia; search for publications in electronic databases (Medline, Embase) from the earliest to January 2023. Conclusions. Changes in angiogenesis markers may indicate the start preeclampsia in pregnant women with chronic hypertension. The values of angiogenesis markers in pregnant women with preeclampsia on the background of chronic hypertension may differ from those in pregnant women with preeclampsia, but without concomitant diseases. In addition, abnormalities in values of angiogenic markers in pregnant women with chronic hypertension compared to normotensive pregnant women may occur without the addition of preeclampsia. The reason may be the effect of chronic hypertension on the development and functioning of the placenta or an altered response of the endothelium to angiogenesis factors. No conflict of interests was declared by the authors.
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Preeclampsia is represented by hypertension and proteinuria in pregnancy. It usually occurs after 20 gestational weeks. There are few reports on preeclampsia before 20 gestational weeks. In this case, we report a patient with chronic hypertension superimposed with preeclampsia at 13 gestational weeks.
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The purpose of this study was to investigate the relationship between parity, maternal age at delivery, gestational age, and duration of the second stage of labor. In this article a retrospective analysis of deliveries during the period from 2000 to 2005 in our Institution was made. We recorded 208 pregnant women under the age of 20 years, 6,115 between 20 and 40 years, and 188 over the age of 40 years considering parity, duration of second stage of labor, birth weight, and gestation age. The correlation of the above parameters was statistically analyzed. In primigravidas, under the age of 20 years, the second stage of labor was significantly shorter compared to women aged over 40 years, and significantly shorter compared to women between the age of 20 and 40 years. Gestational age at delivery was significantly shorter in women aged over 40 years compared to those under the age of 20 years as well as to those between 20 and 40 years of age. Age was positively correlated to the duration of the second stage of labor and negatively correlated to the gestation age at delivery. In multigravidas, age was negatively correlated to the gestational age at delivery. In primigravidas, maternal age was positively correlated with the duration of the second stage of labor. On the contrary, gestational age at delivery was negatively correlated with maternal age. In multigravidas, a negative correlation between maternal age and gestational age at delivery was statistically significant.
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( BJOG . 2021;128:1373–1382) Hypertensive disorders of pregnancy include preeclampsia, gestational hypertension (developing at or after 20 wk’ gestation), and chronic hypertension (diagnosed before 20 wk’ gestation, or before pregnancy). Of these, preeclampsia is associated with the highest risks for parturient and neonate. Gestational or chronic hypertension often develops into preeclampsia. Preeclampsia is typically defined by new proteinuria, though patients with chronic or gestational hypotension may face severe complications without the presence of proteinuria. Some countries have adopted a broader definition of preeclampsia, not requiring proteinuria for diagnosis and also using evidence of placental or maternal end-organ dysfunction. This secondary analysis of the Control of Hypertension in Pregnancy Study (CHIPS) aimed to compare the abilities of the traditional and broad definitions of preeclampsia to identify patients with chronic or gestational hypertension at risk of adverse outcomes.
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To clarify the role of endothelial cells in pregnancy-related hypertensive disorders, we studied the cytotoxic effect of sera from normal pregnant women and from gravidas with various hypertensive complications of pregnancy.We obtained serum samples from 84 Japanese women: 17 with preeclampsia, ten with gestational hypertension, six with chronic hypertension, five with chronic hypertension with superimposed preeclampsia, 21 normal gravidas, and 25 healthy nonpregnant women. Endothelial cell injury was measured by the release of radiolabeled chromium from the cells into the culture medium.The mean (+/- standard error of the mean) values of chromium 51 release in preeclampsia, gestational hypertension, chronic hypertension, chronic hypertension with superimposed preeclampsia, normal pregnancy, and healthy nonpregnant women were: 21.9 +/- 2.1, 10.0 +/- 2.0, 9.2 +/- 2.3, 12.9 +/- 0.8, 8.4 +/- 1.4, and 7.3 +/- 1.6%, respectively. Normal pregnant and nonpregnant subjects did not differ with respect to endothelial cell injury. Sera from women with preeclampsia demonstrated significantly greater endothelial cell injury than did sera from normal gravidas. Subjects with the three other categories of hypertensive disorders did not differ significantly from normal gravidas.Preeclampsia is characterized by the presence of a serum factor cytotoxic to endothelial cells. Therefore, the mechanism responsible for the increase in blood pressure differs between women with preeclampsia and those with other hypertensive disorders in pregnancy.
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To determine risk factors of superimposed preeclampsia in women with essential chronic hypertension receiving antihypertensive therapy prior to conception.A retrospective study of 211 patients that analyzed risk factors of superimposed preeclampsia at first prenatal visit. Variables with a p<.1 at univariate analysis were included in a logistic regression analysis. P<.05 was considered as significant.Superimposed preeclampsia occurred in 49 (23.2%) women. In logistic regression analysis, previous preeclampsia [OR: 4.05 (1.61-10.16)], and mean arterial blood pressure of 95 mmHg or higher [OR: 4.60 (1.94-10.93)] were associated with increased risk of superimposed preeclampsia. When both variables were present, sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio for superimposed preeclampsia were 43%, 94%, 70%, 85%, and 7.71 (95% CI: 3.20-18.57), respectively.In essential chronic hypertensive women, previous preeclampsia and mean arterial blood pressure of 95 mmHg or higher are associated with increased risks of superimposed preeclampsia.
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Synopsis: In this protocol, Dr. Sibai reviews the pathophysiology, diagnosis, and management of preeclampsia. Included are algorithms for management of mild hypertension-preeclampsia and severe preeclampsia. As the author notes, women who develop preeclampsia in their first pregnancy are at increased risk (20%) for development of preeclampsia in subsequent pregnancies. With severe disease in a first pregnancy, the risk of recurrence is about 30%. With severe disease presenting in the second trimester, the risk of recurrent preeclampsia is 50%. There is an increased risk of chronic hypertension and undiagnosed renal disease, especially in patients with two episodes of severe preeclampsia in the second trimester. These patients should have adequate medical evaluation postpartum. There is also increased risk of intrauterine growth restriction in a subsequent pregnancy.
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To assess whether routine induction of labor at 38 or 39 weeks in women with chronic hypertension is associated with the risk of superimposed preeclampsia or cesarean delivery.We conducted a retrospective population-based study of women with chronic hypertension who had a singleton hospital birth at 38 0/7 weeks of gestation of gestation in Ontario, Canada, between 2012 and 2016. Women who underwent induction of labor at 38 0/7 to 38 6/7 weeks of gestation for chronic hypertension (n=281) were compared with those who were managed expectantly during that week and remained undelivered at 39 0/7 weeks of gestation (n=1,606). Separately, women who underwent induction of labor at 39 0/7 to 39 6/7 weeks of gestation for chronic hypertension (n=259) were compared with women who remained undelivered at 40 0/7 weeks of gestation (n=801).Of 534,529 women gave birth during the study period, 6,054 (1.1%) had chronic hypertension and 2,420 met the inclusion criteria. Women managed expectantly at 38 or 39 weeks of gestation were at risk of new-onset superimposed preeclampsia (19.2% [308/1,606] and 19.0% [152/801], respectively) and eclampsia (0.6% [10/1,606] and 0.7% [6/801], respectively), and more than half underwent induction of labor later in gestation (56.8% and 57.8%, respectively). The risk of cesarean delivery in the induction groups was lower (38 weeks of gestation) or similar (39 weeks of gestation) to that observed in women managed expectantly at the corresponding weeks (38 weeks of gestation: 17.1% vs 24.0%, adjusted relative risk 0.74 [95% CI 0.57-0.95]; 39 weeks of gestation: 20.1% vs 26.0%, adjusted relative risk 0.90 [95% CI 0.69-1.17]).Our findings suggest that in women with isolated chronic hypertension, induction of labor at 38 or 39 weeks of gestation may prevent severe hypertensive complications without increasing the risk of cesarean delivery.
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