Management of pregnancy in elderly obese women

27.1

Prevalence

The mean age at childbearing in Europe rose to 29.4 in Europe in 2015. According to the CDC report, there was a significant increase in the number of births to women aged 45–49 years between 1990 and 2010, rising from 0.39/1000 deliveries in 1990 to 1.79/1000 in 2010. According to another US report from 2006–2007 to 2014–2015, there was there was an increase in number of births of 8% for women aged 40–44 years, and 26% for women aged 45–54 years.

27.2

Pregnancy outcomes in relation to advanced maternal age

Fertility gradually declines as a woman matures, starting from 32 years of age, due to a decline in oocyte quality and quantity, and fecundability subsequently declines at around the age of 37 years.

Therefore there is an increasing demand for ART services.

Newer developments in ART have helped women with pathological conditions—poor oocyte quality diminished ovarian reserve or primary ovarian insufficiency—who can benefit from oocyte donation (OD).

OD programmes have also enabled perimenopausal and even postmenopausal women to conceive.

Conception issues:

• Decreased fertility OR(odds ratio) 2

• Increased demand for ART OR:1.5–2

First trimester complications:

• A four- to eightfold increased risk of ectopic pregnancy due to accumulation of risk factors over time (previous pelvic infections, prolonged smoking, tubal pathology, decreased tubal function, and a delay of oocyte transportation).

• A higher incidence of multiple pregnancies.

• Increased risk of spontaneous miscarriages, associated with increased risk of trisomy and other euploidy, especially Down syndrome.

• The increased incidence of nonchromosomal congenital malformations and birth defects, as neonates born to women aged >40 years had a twofold increased risk for cardiac defects, oesophageal atresia, and craniosynostosis even after adjusting for BMI and ART.

27.3

Late pregnancy complications

Chronic hypertension and type 2 diabetes are more common among older pregnant women, and women >35 years of age are at a two to fourfold higher risk of having hypertension compared to women <35.

There is higher risk of developing preeclampsia in women aged over 40 years, The incidence of both pregestational and gestational diabetes mellitus is three to sixfold in gravid women over the age of 40 years, approaching to almost 30% in gravid women aged >50.

There is increased incidence of placental abruption, as well as placenta praevia. Nulliparous women aged >40 years have a 10-fold increased risk for placenta praevia compared to nulliparous women aged 20–29 years (absolute risk of 0.25% vs. 0.03% respectively).

There is a higher incidence of low birth weight and preterm births and the relative risk was 1–9 in women >35 years of age, compared to women aged 20–24 years old.

Among ART pregnancies, especially those achieved via OD, there was a higher risk for preeclampsia, preterm birth, and small for dates, compared to those who conceived naturally,

According to CDC data, the mortality rate among pregnant women <35 years of age is 10.8 per 100,000 births, compared to 38 deaths/100,000 births in women aged >35.

27.4

Intrapartum and postpartum complications

Obesity poses a higher incidence of elective caesarean sections and second stage labour dystocia and operative vaginal delivery. A significantly increase risk of postpartum haemorrhage, need for blood transfusion, prolonged hospitalisation and admission to intensive care unit. Additionally, increased maternal age is associated with an increased risk of still birth.

Risks related to obesity which will have cumulative effect on pregnancy outcome :

• Miscarriage: the higher the BMI, the higher the risk of spontaneous Miscarriages

• Increased congenital abnormalities as neural tube defects, hydrocephaly, cardiovascular and limb reduction abnormalities

• Hypertensive disorders of pregnancy

• Gestational diabetes

• Venous thromboembolism (VTE)

• Sleep apnoea

• Foetal macrosomia (increases shoulder dystocia with its sequalae as brachial plexus injury)

• Stillbirth

• Increased caesarean delivery

• Higher risk of dysfunctional and pronged labours

• Increased incidence of induction of labours (IOL), and more failed IOL

• Low success rates at vaginal birth after caesarean section

• Anaesthetic complications especially with citing epidural in labour and general anaesthesia

• Endometritis, wound infection and dehiscence, and surgical site infections

• For those who had bariatric surgery, there is increased risk of nutritional deficiencies, advise them to wait for 12–18 months at least after surgery to address nutritional deficiency before embarking on pregnancy.

• Among those with prior bariatric surgery, there is a higher incidence of intrauterine growth restriction, thus requiring close monitoring of foetal development.

• Postpartum depression