Obstetric Outcomes in Advanced Maternal Age among Women at King Abdulaziz University Hospital ()
1. Introduction
Despite variations in definition, advanced maternal age is widely defined as maternal age exceeding 35 years [1]. Nowadays, women tend to delay motherhood for various biopsychosocial reasons, including the availability of effective contraception and modern fertility treatment options, as well as delaying marriage and focusing on career and career development [2]. It is well known that both mother and fetus are prone to various obstetric and neonatal complications when pregnancy occurs after age 35, such as spontaneous miscarriage, preterm labor, gestational diabetes mellitus (GDM), gestational hypertension, and preeclampsia/toxemia (PET), stillbirth, and cesarean section (CS) delivery [3] [4]. Therefore, women over 35 should be counseled about possible maternal and neonatal risks and complications associated with pregnancy at advanced maternal age.
In 2020, an 18-year-long retrospective study conducted in Jeddah, Saudi Arabia among 79,095 women concluded that the risk of adverse maternal and obstetric complications such as antepartum hemorrhage (APH), postpartum hemorrhage (PPH), GDM, hypertension, premature rupture of membranes (PROM), and CS delivery increased with maternal age, as did fetal and neonatal complications such as low birth weight, macrosomia, admission to the neonatal intensive care unit, congenital anomalies, and low Apgar score [2].
In general, studies on pregnancy outcomes associated with advanced maternal age are scarce in Saudi Arabia. Therefore, this study aims to determine the most common maternal and neonatal complications among women above 35 years in our facility.
2. Subjects and Methods
This retrospective, record-based study included 199 women over the age of 35 years. It was conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia, from January to June 2022, after approval of the institution’s ethical committee board was granted (Reference No. 350-22). We reviewed outpatient clinic records of pregnant women attending antenatal visits at KAUH who were older than 35 years. Any woman, primigravida or multigravida, who had undergone spontaneous or induced delivery was included in this study. Women aged above 51 and those with pregestational chronic medical illnesses such as diabetes, hypertension, bleeding disorders, hemolytic diseases, immunological diseases, or ectopic pregnancy were excluded. We drafted a checklist to guide the collection of demographic data, number of antenatal visits, ultrasound findings, medications and multivitamins taken during the current pregnancy, smoking status, mode of delivery, pregnancy complications, and neonatal outcomes. Patients’ medical records were reviewed using the Phoenix database at KAUH.
3. Data analysis
We performed statistical analysis on the collected data using IBM SPSS Statistics (Version 26). The chi-square test (χ2) was applied to qualitative data, expressed as numbers and percentages, to examine the relationship between variables. The Kruskal Wallis and Mann-Whitney tests were used to analyze the relationship between quantitative nonparametric variables, expressed as mean ± standard deviation (SD).
4. Results
The mean age of patients was 38.13 ± 2.68 years. The majority were nonsmokers (98.5%), and 79.9% were of Saudi nationality. Among the patients, 70.9%, 1.5%, and 15.6% had dating and viability scans, nuchal translucency scans, and anatomy scans done, respectively. Moreover, 46.7% had growth scans performed during the second trimester and 41.7% during the third trimester. Most patients (64.3%) were taking medications during pregnancy, including tocolytic agents, progesterone, insulin, oral hypoglycemic agents, anticoagulants, antibiotics, glucocorticoids, opioids, proton pump inhibitors, beta-blockers, antihypertensive medications, and thyroid hormone replacement. Approximately 31.2% took folic acid, and 68.8% took multivitamin supplements (Table 1).
The overall prevalence of obstetric complications was 71.4%. Specifically, the prevalence of PET, APH, PPH, and GDM was 4.5%, 4%, 1%, and 23.1%, respectively. Only 12.6% had fetal complications, with preterm labor being the most common complication (48%). Among the patients, 10.1% developed anemia in the first trimester, 21.1% in the second, and 28.6% in the third. About half of the patients (45.7%) were delivered by CS, and only 2% had multiple gestations (Table 2).
More than half of the patients (59.8%) underwent routine screening for GDM at 24 to 28 weeks gestation: 24.1% had a confirmed diagnosis of GDM, and 40.2% of participants did not document the GDM status. For 15.6% of the women, pregnancy continued beyond 40 weeks, and for most participants (66.3%), gestational age was based on their last menstrual period (Table 2). It was considered missed/unknown for our study.
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Table 1. Demographic data and key variables of included women (N = 199).
US, ultrasonography.
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Table 2. Pregnancy, fetal complications, and mode of delivery among the studied women (N = 199).
GDM, gestational diabetes mellitus; PPROM, preterm premature rupture of membranes; US, ultrasonography.
Results from the Mann-Whitney test showed a significant relationship between maternal age and the use of folic acid (p ≤ 0.05). However, a nonsignificant relationship was found between mean maternal age and smoking status, medication use, and postdate pregnancy (p ≥ 0.05), as shown in Table 3.
A significant relationship was found between mean maternal age (38.84 ± 2.75 years) and the development of maternal complications compared with those who did not develop complications (37.84 ± 2.6 years; p ≤ 0.05). However, a nonsignificant relationship was found between mean maternal age and all fetal complications (p ≥ 0.05) (Table 4).
The percentage of fetal complications was significantly higher among mothers who developed APH and anemia in the second trimester (p ≤ 0.05). However, a nonsignificant relationship was found between fetal complications and postdate pregnancy (p ≥ 0.05) (Table 5). In addition, mothers who developed APH or PPH had a higher percentage of anemia in the second trimester (p ≤ 0.05). However, a nonsignificant relationship was found between PET and GDM with anemia in all pregnancy trimesters (Table 6).
5. Discussion
This study assessed the obstetrical outcomes of advanced maternal age among pregnant women in the hospital’s facility. The result shows that the overall obstetric and maternal complications were statistically associated with mean maternal age. In addition, the prevalence of obstetric complications related to advanced maternal age was 71.4%. This percentage is higher than previously recorded in another study performed in 2020 in Ethiopia among 398 women, in which the authors conclude that 64.6% of women aged 35 and above had significantly higher adverse pregnancy outcomes [5].
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Table 3. The relationship between mean maternal age and supplement use, smoking, current medications, and postdate pregnancy (N = 199).
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Table 4. Relationship between mean maternal age and fetal and maternal complications (N = 199).
PPROM, preterm premature rupture of membranes; IUFD, intrauterine fetal death. * Mann Whitney test. ** Kruskal Wallis test.
Preterm labor was the most significant obstetric complication in our study, reaching a prevalence of 48%. This result is higher than a Saudi Arabian cohort study done in 2017 among 3415 women, which reported a percentage of 26.7% [6]. In addition, these results are higher than a prospective study conducted in India in 2014 among 1263 women, which found a percentage of 17.5% [7].
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Table 5. Relationship between fetal complications and maternal complications and postdate pregnancy (N = 199).
Pre-eclampsia/toxemia (PET) is the typical hypertensive disorder linked to advanced maternal age [8]. Our study found a prevalence of 4.5%, which is comparable to a previous retrospective study conducted in our facility published in 2020. This study included 3942 singleton deliveries found that advanced maternal age was a statistically significant factor for developing PET during pregnancy, with a prevalence of 4.2% [9]. These results reflect those of Nunes et al. (2020), which included 301 pregnant women and showed a slightly higher prevalence of PET (6%) [10].
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Table 6. Relationship between maternal complications and anemia in each trimester of pregnancy (N = 199).
The prevalence of GDM in our study was 23.1%, a finding supported by a larger sample size cohort study conducted on 3415 participants in 2017 in Riyadh, Saudi Arabia, showing a high prevalence of GDM among women ≥ 35 years (64.3%) [6]. In addition, a study in Jeddah in 2021 showed a prevalence of 32% [11]. Moreover, a more recent study documented a prevalence of 18.2% [2].
Concerning APH, the prevalence in our study was 4%, which is comparable to a study conducted by Pawde et al. in 2015, showing a prevalence of 6.4% [7]. Furthermore, another study conducted in 2020 in Ethiopia on 398 participants reported that advanced maternal age > 35 years correlates with a 16% increase in APH [5]. However, the prevalence of PPH was only 1%. This finding contrasts a study done in Jeddah in 2022 on 1586 women, which demonstrated a significant relationship between PPH and advanced maternal age, with a prevalence of 43% [11].
Almost half of the women in our study delivered via a cesarean section (45.7%), confirming the correlation between advanced maternal age and CS delivery. Similarly, a study conducted in Jeddah, Saudi Arabia, in 2021 found a significant association between AMA and the prevalence of CS delivery (43.6%) [11]. In addition, a study conducted in 2020 in Ethiopia reported a two-fold increase in the rate of cesarean delivery associated with advanced maternal age [5].
Among this study’s participants, 10.1%, 21.1%, and 28.6% had anemia in the first, second, and third trimesters, respectively. This outcome is comparable to a previous study conducted in the Northern region of Saudi, where 16.8% of the women were of advanced maternal age, 17.1% had anemia on their first visit to the GP, and 45.2% were found to have anemia later in the pregnancy [12] [13].
Finally, this study found that the prevalence of post-date pregnancy was 31%. However, a different study conducted in the Netherlands in 2020 found a correlation between AMA and post-date pregnancy, with a smaller percentage of 13.1%.
6. Limitations and Areas for Future Research
This study was limited to a single center and only 199 patients. Consequently, it is possible that our findings do not necessarily reflect the complications in other distinct and larger populations. Furthermore, using a retrospective study design hinders the generalizability of our study’s findings. Other limitations include missing data from some of the patients’ records. Nevertheless, these limitations pave the way for future research opportunities, as the findings of this study can give greater validity and credibility using alternative methods, a larger sample size, different populations, and a multicenter approach.
7. Conclusion
Our findings confirm that pregnancy at an advanced maternal age increases the risk of developing several obstetric and neonatal complications, as reported in the literature. However, the most frequent complication we found was preterm labor. Other complications, such as PET, APH, PPH, GDM, and anemia during pregnancy were less frequent.
Acknowledgements
The authors gratefully acknowledge the cooperation of the administrative staff of the study setting.