646 La Rewue de Santé de la Méditerranée orientale, Vol. 7, N° 4/5, 2001 Advanced maternal age and pregnancy outcome VN. Amarin’ and H.F. Akasheh' bad dra Ne NN us ols BS ap poy gp tie HIS Belli ode OE bab J yeasty ted gl LLIN Le A pe Aas UT galt fot pe eb Be 35 le gpaglest 5 N73 go Jab! Jpaty fad oliclnny dtd pli OM Ces yale 9 182,NU og Sen do poh gitiwe ole 0035 oof Bie 255 20 ce aylasl csr al vt aty Cia! At tira pa Catan of gfe oy 2000 wed ly 1999 Jo glolp a om Ena MPa] Up Bend Bah yt op hey ee 9ST oa gpl sl owe lel gg Sty pL hie NEY! patch CAS Iai casa gh JS Spy cptlyal Jory (21) gana E15 y pnt US SLALT 3a, OF Se aL aoe WEY Sip 3 ede WG IL ple of WAU 5 potty De ab Je its Gide bgp ABSTRACT To assess the effect of maternal age on obstetric intervention and pregnancy outcome, a retrospective study compared obstetric intervention, pregnancy complications and outcome in 73 women of ‘age > 35 years with 471 women of age 20-25 years attending Prince Ali Military Hospital, Jordan trom June 1988 to May 2000. Older women were found to have significantly higher rates of medical complications auch ‘as hypertension and diabetes melitus. Despite signticantly increased frequency of large babies, trisomy 21, ‘win pregnancy and antepartum haemorrhage, overall outcome was satisfactory. We conclude that older women. managed by modem obstetric methods and delivered in a modern health-care centre. can expect (good pregnancy outcomes. ‘Age avancé de la mére et issue de la grossesse RESUME Alin c'évaluer effet de age de la mere sur intervention obstétricale et issue de la grossesse, une ‘étude rétrospective a comparé intervention cbstétricale, les complications survenant durant la grossesse et issue de la grossesse chez 73 femmes de plus de 25 ans par rapport & 471 femmes Agées de 20425 ans qui consullatent @ rnopital mutaire Prince Al (Jordame) de juin T8¥y a ma Z0UV, Un a trouve que les fommes plus Agées avaient des taux significativement plus 6levés de complications médicales telles que hypertension et le diabéte suoré. Malgré une augmentation importante de la fréquence des bébés corpu- fenta, de la trisomie £1, des grossoasea gémellaires ot dos hémorragios prénatalea, Noaue globale était satisfaisante, Nous concluons que les femmes plus 4gées, prises en charge par des méthodes obstetri- ‘cales modemes ot ayant accouché dans un centre de soins de santé modeme, peuvent espérer une bonne issue da leur grossasse "Department of Obstetrics and Gynaecology, Prince Ali Miltary Hospital, Karak, Jordan. Received: 16/11/00; accepted: 11/0104 Yeah comk Slate egulh Alea Able Genel Lelie caelEaster Meciterranean Health Journal, Vol. Introduction Advanced maternal age is considered rela tively more hazardous from both the mater- nal and fetal perspectives [7]. The optimal childbearing age ie 20 25 years [J]. In- creasingly however, women are delaying pregnancy until the fourth or fifth decades of life. The reasons for the delay are multi- ple, including late marriages, contraception techniques, higher education and career prospects [2]. In Jordan, many women continue to have children because of cul- tural attitudes towards large families, or be- cause the decision is not theirs to make. Although the impact of advanced ma- ternal age and parity on pregnancy out- come has become increasingly important, the definition of what constitutes advanced maternal age in the obstetric literature is variable, Most authors have designated a lower limit of 35 years [/, 3,4], while others have used 40 years [2,5]. A recent article by Duliteki et al. proposed that women aged > 44 years be considered of advanced maternal age [6]. Regardless of the lack of ‘agreement in defining advanced maternal age, pregnancies in women aged > 35 years are considered to be of high risk [/]. The aim of thie study was to assess the effect of maternal age on obstetric intervention and pregnancy outcome in a modern health care centre. Methods In this retrospective study we compared obstetric intervention, pregnancy compli- cations and outcome in two groups of. women. Group I consisted of 73 women > 35 years of age (range: 35-46 years), A control group (group 11) consisted of 471 women (age range: 20-25 years). All wom- en whose ages fell within either of these Nos 4/6, 2001 647 ranges were included in the study, regard- less of previous medical, surgical or obstet- ric history. All deliveries took place at Prince Ali Military Hospital from June 1999 to May 2000, and were conducted by mid- wives unless medical intervention was nec- essary. Statistical analysis was carried out us- ing the chi-squared and Fisher exact tests. PS 0.05 was considered significant. Results ‘There were 1482 deliveries conducted at Prince Ali Military Hospital during the study period. Table | outlines their age distribu- tion. Table 2 shows that the incidence of caesarean section and instrumental deliver- ies did not significantly differ between the two groups selected for our study. Table 3 shows the serious obstetric and medical ‘complications occurring during the second and third trimesters of pregnancy and la- Table 1 Total deliveries at Prince All Hospital, Jordan, June 1999-May 2000 by age and mode of delivery Variable No. % Age group (years) <2 182 123 20-25 an 31.8 26-30 464 313 31-35 292 197 >35 B 49 Mode otdalivory Normal 1186 800 Caesarean 192 13.0 Forceps 8 09 Vacuum wo 54 Breech 1 oz Y -¥ goal eo Seah dad oad ake ee a. apa deLa Revue de Santé de la Méditerranée orientale, Vol. 7, N° 4/5, 2001 ——— Table 2 Mode of delivery of the two groups, Prince All Hospital, Jordan, June 1999-May 2000 Mode of delivery Group!(n=73) Group!l(n=471) _#(P-value) No % No, % Normal 088 ort 70.8 2.00(>0.03) Caesarean 4 192 7 124 2.79(>0.08) Forceps 0 4 09 1.00(>0.055 ‘Vacuum 8 110 a 79 0.80(>0.05) Breech 0 2 04 1,00(> 0.05%) rister exact test Table 8 Complications during pregnancy and lahour, Prines Ali Hacpital, Jordan, June 1999-May 2000 ‘Complication Group! (n=73) Groupil(n=471) 4? (P-value) No % No. % ‘Twin pregnancy 6 682 10-21 «8.08 (<0.01) Hypettensivedisorders = 1118.1 2% BA 10.95(<0.01) Diabetes mellitus 9 123 2 26 16.28(<0.01) Premature labour 2 27 6 13 0.29(>0.054) Antepartumhaemorhage 12 104 % 79 0.08(« 0.05) Postpartum haemorhage 7 © 96 2% 55 1.78(>.0.05) Table 4 Classification of hypertensive disorders, Prince Ali Hospital, Jordan, June 1000-May 2000 Hypertensive disorder 471) x2 (P-value) % Pre-eclampsia 45 0.34(>0.08) Eclampsia 02 — 1.00(>0.05) Gestational norrprowinuiic Essential Toa 04 — 0.09(<0.05) 0.00(<0.01) Tonk vane ual ghd aecd vaich Donh Solem chong Gad Spa altSSS TT prnpeeeyerrer eer Eastern Mediterranean Health Journal, Vol. 7, Nos 4/5, 2001 649 a” Table 5 Antepartum haemorrhage, Prince Ali Hospital, Jordan, June 1999-May 2000 Condition Group!(n=73) Group il(n=471) _4#(P-value) No. % No. % Placenta praevia 7 96 8 38 4.66(<0.05) ‘Abruptio placentae 3 44 6 32 0.72 (>0.05) Local causes 2 27 3 06 = 0.14 (>0.05%) Total 2 EN “Fisher exact test ‘Table 6 Neonatal outcome, Prince Ali Hospital, Jordan, June 1999-May 2000 Outcome Groupl(n= 78) GroupiI(n=481) _?(Pvaluey ‘No. % No. % ‘Birth weiaht > 4 ka 16 202 RY THAN (ENT) Birth weight < 2.5kg 3 38 a 44 1.00 (> 0.05%) Gestational age > 42 weeks 9 WA 2 66 2.25 (> 0.05) Gestationataye0.05") Five minute Apgar <7 oO 4 08 1,00 (> 0.05") Congenital malformation 4 Bt 1939 0.55(>0.059 Intrautarine fatal death + 42 4 08 0.69 (0.084 "Fisher exact test Table 7 Chromosomal abnormalities, Prince Ali Hospital, Jordan, June 1999— May 2000 Abnormality Group! (n=73) Groupi(a—471) Fisher exact teat No % No. % (P-value) Trisomy 21 5 68 2 04 0.00{< 0.01) Iumer syndrome 1 14 3 06 0.44 {> 0.05) Klinefelter syndrome 0. 1 02 1.00 (> 0.05) Ss YoY orf bul gid aad al oa) Gis sho 3) Gad dal650 La Revue de Santé de fa Méditerranée orientale, Vol. 7, N° 4/5, 2001 bour in the two groups. The occurrence of multiple pregnancies, hypertensive disor- ders, diabetes mellitus and antepartum haemorthage were significantly higher in group I than in the control group. Table 4 claseifies the various types of hypertension encountered. The occurrence of pre-ec- lampsia and eclampsia were not significant ly different, whereas gestational non- proteinuric hypertension and essential hy- pertension were statistically higher in group I. The types of antepartum haemor- thage encountered are summarized in Table 5. Placenta praevia in group I was signifi- eontly higher than in group Il. There was no significant difference in the occurrence of abruptio placentae and local causes. Ta- ble 6 illustrates the neonatal outcome in. both groups. The only statistically signifi- cant differences were fetal birth weight of > 4 keg and chromosomal abnormalities (analysed at the University of Jordan Ge- netics Laboratory). Among the chromo- somal abnormalities shown in Table 7, only trisomy 21 was statistically higher in group 1 compared to controls. Discussion Most women aged > 35 years have healthy pregnancies and babies. However, recent studies suggest that women who postpone childbearing do tace certain special risks. ‘This was borne out in our study, where the risk of multiple pregnancy, hypertensive disorders, antepartum haemorrhage and di- abetes mellitus were increased in the sec- ond and third trimesters compared to younger women. These findings agree with Gilbert et al. [2], Bianco et al. [5] and Berkowitz et al. [7]. Gilbert et al. otudied first-time mothers aged > 40 years and ob- served that these women were 60% more likely to develop high blood prossure and four times more likely to develop diabetes mellitus than mothers in their twenties. The risk of bearing a child with certain chromosomal disorders increases as wom- en age. The most common of these disor- dors is Down syndrom. Indeod, this was the case in our study, where five women from the older age group gave birth to ba- bieo with trcomy 21, compared to only ‘two from the control group, Pregnancy in women of age > 35 years ic aceociated with a high maternal and peri- natal morbidity and mortality [/]. Older pregnant women also have a higher chance of delivery by caesarean section [J], al- though this was not obvious in our study, where abdominal deliveries in older moth- ers were not more frequent than in the con- trols. Contrary to reported data [J]. thé difference in frequency of instrumental de- liveries in our study was also not statistical. ly significant between the two groups. The literature indicates that pregnant women of advanced age, in goad health, do not need special care beyond normal ob- stetric practice [/]. Advances in medical care now help women in their late thirties and forties to have safer pregnancies than in the past. However, women should be aware of the rick ascnciated with delayed childbearing so they can make informed decisions on when to start their families. References 1. van Katwijk C, Peeters LL. Clinical as- pects of pregnancy after the age of 35 years: a review of the literature. Human reproduction update, 1990, 4:105-94, 2. Gilbert WM, Nesbitt TS, Danielsen B. Childbearing beyond age 40: pregnancy outcome in 24 032 cases. Obstetrics and gynecology, 1998, 90:9-14. Veet coo sieht tinal al dee Ge che Sal tal adsEaster Mediterranean Health Journal, Vol, 7, Nos 4/5, 2001 651 3. Frets RC, Usher RH. Causes of fetal 6. Dulitzki M et al. Effect of very advanced death in women of advanced maternal maternal age on pregnancy outcome age. Obstetrics and yynecvioyy, 1997, und rate of Gusurean delivery, Gosterrics 89:40-5. nd gynecology, 1998, 92:935-9. 4. Romero Gutiérrez G et al. Motbilidad y 7, Berkowitz GS ot al, Delayed childbear- mMortalidad materno fetal en embaraza- das de edad avanzada. (Maternal-fetal morbidity and mortality in advanced ing and the outcome of pregnancy. New England journal of medicine, 1990, 322: 659-64. ago.] Ginocologia y obstetricia de Méxi- co, 1999, 67:239-45. 5. Bianco A et al. Pregnancy outcome at age 40 ana older, Onsteirics and gyne- cology, 1996, 87:917-22, Transforming health systems: gender and rights in reproductive health: a training curriculum for health programme managers The title of this manual - Transforming health systems: gender and rights In reproductive health ~ reflects the aspirations of the inivative. The aspiration is to reform health systems to enable reproductive (and all other) health services to be gender sensitive and to uphold rights. The curriculum evolved over a five-year process that brought together people with diverse skills from different regions of the world, and in- cluded conducting the course in different parts of the world and learn- Ing from participants. The manual offers a session-based and case-based curriculum on how to promote gender equity and reproductive rights through the use of evidence, policy development and service delivery The curriculum Is founded on the premise that the development of workable reproduc- tive health programmes calls for training that not only includes new technical skills, but faces head-on the challenae of changing ap- proaches and perspectives. It aspires to transform health workers, managers and policy makers into active change agents committed to transformation of health systems. The manual is in three parts. The first part includes a brief background to the course and practical details about the course. The second part contains the six teaching modules with an opening and a closing mod. ule, and the third part contains annexes with tools and resources. The manual is available from: World Health Organization, Department of Reproductive Health and Research, CH-1211 Geneva 27, Switzerland. it 15 also available free on the Intemet at; http.//whallpdoc. who.int/hal 2001 /WHO _RHR_O1.29.pdf DRI GP Mae IWS owed Cele dee gl 32) Soma al