Abstract
Background:
Pregnant women of extremes of reproductive age group at both ends (< 20 years and > 35 years age) comprise high risk groups. Pregnant women up to 35 years get many complications like diabetes, spontaneous abortion, hypertensive disorders, autosomal trisomies, increased newborn and maternal morbidity and mortality and cesarean sections. Pregnancies of < 18 years age group is complicated by anemia, preterm labor, urinary tract infections, pre-eclampsia, and a high rate of cesarean sections, preterm birth, low birth weight and growth retardation of the newborns.Objectives:
Incidence of various antenatal complications, pregnancy outcome and mode of delivery in < 20 years age group and > 35 year age group and to compare both the groups.Methods:
This retrospective study was done at department of obstetrics and gynaecology, Chatrapati Shahuji Maharaj Medical University, Lucknow, from January 2010 to December 2010. Data were collected from institutional logbook and various complications and outcome were studied. Statistical analyses were carried out by using the statistical package for SPSS-15.Results:
Present study showed that the definite increased risk of preeclampsia, eclampsia, obstetric cholestasis, twin gestation, anemia, preterm labor, premature rupture of membranes, intrauterine fetal growth restriction, and intrauterine fetal death in adolescent pregnancies and increased risk of eclampsia, diabetes, and cesarean sections in advanced age pregnancies.Conclusions:
Both adolescent and advanced age groups are high risk pregnancy groups so for best reproductive outcome, pregnancies at these ages should be very carefully supervised with both good maternal and fetal surveillance to achieve best maternal and fetal results.Keywords
1. Background
For good fertility outcome maternal age is an important factor. Pregnant women of extremes of reproductive age group at both ends (< 20 years and > 35 years age) comprise high risk groups. Advanced age pregnancies are more common as result of infertility treatments, changing social and demographic trends [1, 2]. Pregnancies of < 18 years age group is complicated by anemia, preterm labor, urinary tract infections, pre-eclampsia, and a high rate of cesarean sections, preterm birth, low birth weight and growth retardation of the newborns [3-8]. Smoking, unemployment, anemia and chorioamnionitis were found to be risk factors of teenage pregnancies. Teenage women were found to have a higher incidence of chorioamnionitis, which may be the result of several causes such as physiological immaturity of the cervix, specifically alkalinity of vaginal PH, prominence of the squamocellular junction and shorter cervical length [9]. Age-related differences in the prevalence of risk factors such as immunologic naivety to sperm due to sexual inexperience [10], (inadequate blood volume expansion [11], and/or abnormal cytotrophoblastic stem cell differentiation and poor placental invasion due to a deficit of maternal gonadal hormones early in gestation) [12] could predispose adolescents to PIH Pregnancies of > 35 years women get many complications like diabetes, spontaneous abortion, hypertensive disorders, autosomal trisomies, newborn and maternal mortality and cesarean sections [13-20]. The increased incidence of cesarean section is very common in advanced age . One possible explanation is that obstetricians may have a lower threshold for intervention in older women. An alternative explanation is that myometrial function deteriorates with age [21]. This mechanism may also be relevant to the increased age-related risk of breech presentation and postpartum hemorrhage, as uterine atony is the most common cause of postpartum hemorrhage. There was a wider distribution of birth weight in the older women. Although some studies have shown that delayed childbearing is associated with many increased complications of pregnancy but neonatal outcomes has not been shown to be appreciably different from younger women [18]. Jacobsson et al. showed in their studies that prenatal mortality, intrauterine fetal death, and neonatal death increased with age [19]. Pregnancies at both extremes of reproductive age represent many complications during pregnancy and birth which result in increased maternal and newborn morbidity and mortality [22]. The high rates of an ovulation during adolescence and after the age of 35 may be interpreted as an adaptation to high risk pregnancies during these phases of life. The identification of risk groups may enable the design of targeted ante-partum testing regimen which will result in improved outcomes so it is important to identify high risk groups to decrease complications. Although there are studies which have shown association between increased complications in extremes of reproductive age, but there is complete lack of Indian data so this study was done to report our experience at tertiary centre.
2. Objectives
This study is designed to have incidence of various antenatal complications, pregnancy outcome and mode of delivery in < 20 years age group and > 35 years age group and to compare both the groups.
3. Methods
This retrospective study was done at department of obstetrics and gynecology, Chatrapati Shahuji Maharaj University, Lucknow, from January 2010 to December 2010. Data were collected from institutional logbook. Eligibilty for the study was limited to the pregnancies who reached 24 weeks of gestation. Total cases were divided in three groups. Group A consisted teenage pregnancy (< 20 years age), group B had women > 35 years age and group C had women between 20 - 35 years of age. Incidence of antenatal complications like preeclampsia, eclampsia, anemia, cholestasis, preterm labor, premature rupture of membranes, intrauterine growth retardation, placenta previa, placental abruption, polyhydramnios, oligohydramnios, twinning of pregnancy in all three groups calculated. Incidence of various medical disorders like jaundice, hypothyroidism, and heart disease were also find out. Mode of delivery and prenatal outcome were compared. Comparisons between the groups and subgroups were performed with Student t test for continuous data and chi square test or Fisher’s exact test for categorical data. A probability value of < 0.05 was considered significant. Mean and standard deviation (SD) were calculated for continuous variables. Statistical analyses were carried out by using the statistical packages for SPSS-15.
4. Results
During the study period total number of deliveries at tertiary centre were 4720. Out of 4720 deliveries incidence of < 20 years women (group A) (326/4720) and > 35 years women (group B) (329/4720) was approximately similar and was 6.9%. Rest 86% women were between 20 - 35 years (group C). In group A, most women (63%) were primiparous while in group B and group C most women were multiparous (75% and 60%) respectively. Statistically significant difference (< 0.0001) was found in incidence of abortion in group A and group B when compared to group C. On comparing group A with control group C, statistically significant increase in incidence of various antenatal complications was found in group A and these complications were spontaneous abortion, preeclampsia, eclampsia, twin gestation , anemia , preterm labor , premature rupture of membranes , intrauterine fetal growth restriction and intrauterine fetal death. On comparing group B with group C incidence of spontaneous abortion, preeclampsia, anemia, and premature rupture of membranes, intrauterine fetal growth restriction and Lower segment cesarean section (LSCS) was statistically significantly increased in group B. Incidence of LSCS was significantly high (< 0.001) in group B. Although incidence of preterm neonate was significantly high only in group A but low birth weight neonates were significantly more in both the groups A and B. There was not statistically significant difference was found in antenatal complications like placenta previa, abruption, and congenital anomaly in group A and group B when compared to group C. More so ever on comparing group A with group B incidence of preeclampsia , eclampsia, anemia preterm labor, preterm rupture of membranes, intrauterine fetal growth restriction and intrauterine fetal death was statistically significant high in group A.
Demographic Characteristics
| Characteristics | Adolescent Age Group, (Group A) | Advanced Age Group, (Group B) | Control Group, (Group C) | |||
|---|---|---|---|---|---|---|
| Mean Age | Range | Mean Age | Range | Mean Age | Range | |
| Age, y | (17.2 ± 3.1 ) | (16 - 20) | (38.2 ± 2.4) | (35 - 42) | (28.2 ± 3.2) | (21 - 36) |
| Abortion | Number | Percent | Number | Percent | Number | Percent |
| Total | 129 | 39.5 | 198 | 60.1 | 472 | 11.6 |
| A1 | 88 | 68 | 65 | 66 | 318 | 67 |
| > A2 | 41 | 32 | 133 | 34 | 144 | 33 |
| Parity | Number | Percent | Number | Percent | Number | Percent |
| P1 | 207 | 63 | 83 | 25 | 1635 | 40.2 |
| > P2 | 119 | 37 | 246 | 75 | 2430 | 59.7 |
Incidence of Complications in Three Groupsa
| Parameter | Group A (326) | Group B (329) | Group C (4065) |
|---|---|---|---|
| PE | 80 ( 24) | 38 (11) | 304 (7.4) |
| Eclampsia | 38 (11.6) | 6 (1.8) | 98 (2.4) |
| Gestational diabetes | 4 (1.6) | 11 (3. 2) | 12 (3.6) |
| Anemia | 106 (31.6) | 79 (23.9) | 248 (6) |
| Cholestasis | 4 (1.6) | 6 (1.8) | 67 (1.6) |
| Twins | 17 (5.2) | 7 (2.1) | 78 (1.9) |
| Preterm | 72 (22) | 264 (6.4) | 16 (4.8) |
| PROM | 33 (13.1) | 13 (3.9) | 116 (3.8) |
| Placenta Previa | 12 (3.6) | 17 (3.4) | 139 (3.4) |
| Placental Abruption | 5 (1.5) | 2 (0.6) | 42 (1) |
| IUGR | 21 (6.4) | 6 (1.8) | 146 (3.6) |
| IUD | 49 (15) | 26 (7.9) | 281 (6.9) |
| Congenital anomaly | 6 (1.8) | 9 (2.9 ) | 36 (1.1) |
| Obstructed labor | 3 (0.9) | 11 (3.3) | 66 (1.6) |
| Fibroid | 0 | 1 (0.3) | 10(1.2) |
| Rheumatic heart disease | 8 (2.4) | 4 (1.2) | 44 (1.1) |
| Jaundice | 8 (2.4) | 3 (0.9) | 66(1.6) |
| Hypothyroidism | 1 (0.3) | 5 (1.5) | 50 (1.2) |
| Deliveries Vaginal | 178 (54) | 131 (40) | 2296 (56) |
| LSCS | 148 (46) | 198 (60) | 1796 (44) |
| Preterm | 105 (32) | 30 (8.8) | 407(9.3) |
| IUGR | 279 (85.5) | 114 (34) | 1032 (25) |
Comparison of Variables in Extremes of Age Group and Control Group
| Variable | A Versus C | B Versus C | ||
|---|---|---|---|---|
| OR (CI) | P Value | OR (CI) | P Value | |
| Abortion | 5.4 (4.2 - 6.9) | < 0.001 | 12.4 (9.7 - 15.9) | < 0.001 |
| PE | 4 (3.0 - 5.3) | < 0.0001 | 1.6 (1.1 - 2.3 ) | < 0.008 |
| Eclampsia | 3.9 (2.6 - 6 ) | < 0.0001 | 0.75 (0.3 - 1.79 ) | 0.5 |
| Gestatinal diabetes mellitus | 0.75 (0.12 - 0.7) | 1 | 1.1 (03 - 3.8) | 0.7 |
| Anemia | 13.6 (10 - 18.3) | < 0.001 | 4.86 (3.6 - 6.5) | < 0.001 |
| Cholestasis | 0.3 (0.1 - 2.2) | 0.3 | 1.3 (0.4 - 3.9) | 0.5 |
| Twins | 2.8 (1.6 - 4.9) | < 0.001 | 1.1 (0.4 - 2.5) | 0.8 |
| Preterm | 4.1 (3 - 5.5) | < 0.001 | 0.7 (0.4 - 1.2) | 0.2 |
| PROM | 3 (1.9 - 4.7) | < 0.001 | 2 (1.2 - 3.4) | < 0.006 |
| Placenta Previa | 1.1 (0.5 - 2) | 0.9 | 1.5 (0.9 - 2.6) | 0.1 |
| Placental abruption | 1.5 (0.5 - 3.9) | 0.4 | 0.6 (0.1 - 2.5) | 0.7 |
| IUGR | 1.8 (1.1 - 3) | 0.01 | 0.5 (0.2 - 1.1) | 0.12 |
| IUD | 2.4 (1.7 - 3.3) | < 0.001 | 1.19 (0.7 - 1.8) | 0.5 |
| Congenital Anomaly | 2.1 (0.8 - 5.2) | 0.1 | 0.7 (0.1 - 2.9) | 1 |
| Obstructed Labor | 1.1 (0.3 - 4) | 0.7 | 1.9 (0.6 - 5.2) | 0.2 |
| RHD | 2.3 (0.1 - 5.1) | 0.05 | 1.1 (99.3 - 3.2) | 0.7 |
| Jaundice | 1.5 (0.6 - 3.3) | 0.3 | 0.5 (0.1 - 1.8) | 0.4 |
| Hypothyroidism | 0.2 (0.01 - 1.6) | 0.1 | 1.2 (1.4 - 3.2) | 0.6 |
| LSCS | 1.1 (0.8 - 1.3) | 0.5 | 1.2 (1.5 - 2.5) | < 0.001 |
| Preterm neonate | 4.2 (3.3 - 5.5) | < 0.001 | 0.9 (0.6 - 1.35) | 0.67 |
| Small for Gestational age | 17 (12.5 - 24) | < 0.001 | 1.6 (1.2 - 2) | < 0.001 |
5. Discussion
Present study showed definite increased risk of preeclampsia, eclampsia, obstetric cholestasis, twin gestation, and anemia, preterm labor, premature rupture of membranes, intrauterine fetal growth restriction, and intrauterine fetal death in adolescent pregnancies. Previous studies have also focused on the adverse obstetrical outcomes in adolescent maternal age. Lao et al. reported that teenage pregnancies have higher incidence of preterm labor, lower birth weight, and caesarean rate [23]. Contrarily, Raatikainen et al. found no evidence for increased risk of preterm delivery, fetal growth restriction, low birth weight, or fetal or prenatal death in teenage mothers [24]. Hidalgo et al. reported that adolescent maternal age with lower socio-economic status increase the risk for low birth weight, adverse neonatal outcome, and cervicovaginal infections but is not associated with adverse obstetrical outcomes [25]. Advanced maternal age pregnancies have also been determined to have high risk for adverse obstetrical outcomes. The incidences of preeclampsia, gestational hypertension, cesarean delivery, abruption placenta, preterm delivery, and 5-minute Apgar scores < 7 to be significantly higher in the advanced maternal age group in their studies [20, 26]. Luke et al. reported increased abnormal labor, bleeding during labor and higher cesarean section rate in the advanced maternal age group [27]. Similarly, Jolly et al. also showed that complications such as gestational diabetes, placenta previa, cesarean section, postpartum hemorrhage, prematurity, low birth weight and stillbirth have higher frequency among women with advanced maternal age [28]. In contrast, Kale et al. reported that advanced maternal age with high parity is not always related with adverse maternal outcomes [29]. Present study showed increased risk of eclampsia, diabetes and caesarean section in advanced age pregnancies. In older literature (e.g. Moerman 1982) [30], the increased risk of cesarean section among teenage mothers was mentioned, however according to more recent papers no increased rate of cesarean sections is found among very young adolescent mothers [22, 23, 31]. The results of the present paper support these findings, as the teenage mothers of the present sample had the lowest rate of cesarean sections of the whole sample. This might be due to the improved medical supervision of the teenage pregnancies.
5.1. Conclusion
To our best of knowledge there is paucity of Indian data regarding reproductive outcomes in extremes of age group. Both adolescent and advanced age groups are high risk pregnancy groups so for best reproductive outcome, pregnancies at these ages should be very carefully supervised with both good maternal and fetal surveillance
References
-
1.
Studzinski Z. Pregnancy and delivery in women over 40 years old. Wiadomosci lekarskie. 2004;57(3-4):140-4.
-
2.
Chan BC, Lao TT. Influence of parity on the obstetric performance of mothers aged 40 years and above. Hum Reprod. 1999;14(3):833-7. [PubMed ID: 10221722].
-
3.
Weerasekera DS. Adolescent pregnancies--is the outcome different? Ceylon Med J. 1997;42(1):16-7. [PubMed ID: 9164024].
-
4.
Watcharaseranee N, Pinchantra P, Piyaman S. The incidence and complications of teenage pregnancy at Chonburi Hospital. J Med Assoc Thai. 2006;89 Suppl 4:S118-23. [PubMed ID: 17726815].
-
5.
Usta IM, Zoorob D, Abu-Musa A, Naassan G, Nassar AH. Obstetric outcome of teenage pregnancies compared with adult pregnancies. Acta Obstet Gynecol Scand. 2008;87(2):178-83. [PubMed ID: 18231885]. https://doi.org/10.1080/00016340701803282.
-
6.
Sagili H, Pramya N, Prabhu K, Mascarenhas M, Reddi Rani P. Are teenage pregnancies at high risk? A comparison study in a developing country. Arch Gynecol Obstet. 2012;285(3):573-7. [PubMed ID: 21789518]. https://doi.org/10.1007/s00404-011-1987-6.
-
7.
Ozdemirci S, Kasapoglu T, Cirik DA, Yerebasmaz N, Kayikcioglu F, Salgur F. Is late adolescence a real risk factor for an adverse outcome of pregnancy? Maternal-Fetal Neonat Med. 2016:1-4.
-
8.
Buitendijk SE, van Enk A, Oosterhout R, Ris M. [Obstetrical outcome in teenage pregnancies in The Netherlands]. Ned Tijdschr Geneeskd. 1993;137(49):2536-40. [PubMed ID: 8272140].
-
9.
Stevens-Simon C, Beach RK, McGregor JA. Does incomplete growth and development predispose teenagers to preterm delivery? A template for research. J Perinatol. 2002;22(4):315-23. [PubMed ID: 12032796]. https://doi.org/10.1038/sj.jp.7210694.
-
10.
Smith GN, Walker M, Tessier JL, Millar KG. Increased incidence of preeclampsia in women conceiving by intrauterine insemination with donor versus partner sperm for treatment of primary infertility. Am J Obst Gynecol. 1997;177(2):455-8.
-
11.
Stevens-Simon C, McAnarney ER. Adolescent maternal weight gain and low birth weight: a multifactorial model. Am J Clin Nutr. 1988;47(6):948-53. [PubMed ID: 3287895].
-
12.
Zhou Y, Damsky CH, Chiu K, Roberts JM, Fisher SJ. Preeclampsia is associated with abnormal expression of adhesion molecules by invasive cytotrophoblasts. J Clin Invest. 1993;91(3):950-60. [PubMed ID: 7680671]. https://doi.org/10.1172/JCI116316.
-
13.
Peipert JF, Bracken MB. Maternal age: an independent risk factor for cesarean delivery. Obstet Gynecol. 1993;81(2):200-5. [PubMed ID: 8423950].
-
14.
Milner M, Barry-Kinsella C, Unwin A, Harrison RF. The impact of maternal age on pregnancy and its outcome. International journal of gynaecology and obstetrics: The official organ of the international federation of gynaecology and obstetrics. 1992;38(4):281-6.
-
15.
Berkowitz GS, Skovron ML, Lapinski RH, Berkowitz RL. Delayed childbearing and the outcome of pregnancy. N Engl J Med. 1990;322(10):659-64. [PubMed ID: 2304491]. https://doi.org/10.1056/NEJM199003083221004.
-
16.
Ziadeh S, Yahaya A. Pregnancy outcome at age 40 and older. Arch Gynecol Obstet. 2001;265(1):30-3. [PubMed ID: 11327090].
-
17.
Roberts CL, Algert CS, March LM. Delayed childbearing--are there any risks? Med J Aust. 1994;160(9):539-44. [PubMed ID: 8164551].
-
18.
Melchor JC, Rodriguez-Alarcon J, Fernandez-Llebrez L, Benito JA, Linares A, Aranguren G. Delayed childbearing and pregnancy outcome. Zentralbl Gynakol. 1994;116(10):566-70. [PubMed ID: 7810244].
-
19.
Jacobsson B, Ladfors L, Milsom I. Advanced maternal age and adverse perinatal outcome. Obstet Gynecol. 2004;104(4):727-33. [PubMed ID: 15458893]. https://doi.org/10.1097/01.AOG.0000140682.63746.be.
-
20.
Bianco A, Stone J, Lynch L, Lapinski R, Berkowitz G, Berkowitz RL. Pregnancy outcome at age 40 and older. Obstet Gynecol. 1996;87(6):917-22. [PubMed ID: 8649698].
-
21.
Rosenthal AN, Paterson-Brown S. Is there an incremental rise in the risk of obstetric intervention with increasing maternal age? Br J Obstet Gynaecol. 1998;105(10):1064-9. [PubMed ID: 9800928].
-
22.
Perry RL, Mannino B, Hediger ML, Scholl TO. Pregnancy in early adolescence: are there obstetric risks? J Matern Fetal Med. 1996;5(6):333-9. [PubMed ID: 8972410]. https://doi.org/10.1002/(SICI)1520-6661(199611/12)5:6<333::AID-MFM8>3.0.CO;2-Q.
-
23.
Lao TT, Ho LF. The obstetric implications of teenage pregnancy. Hum Reproduct. 1997;12(10):2303-5.
-
24.
Raatikainen K, Heiskanen N, Verkasalo PK, Heinonen S. Good outcome of teenage pregnancies in high-quality maternity care. Eur J Public Health. 2006;16(2):157-61. [PubMed ID: 16141302]. https://doi.org/10.1093/eurpub/cki158.
-
25.
Hidalgo LA, Chedraui PA, Chavez MJ. Obstetrical and neonatal outcome in young adolescents of low socio-economic status: a case control study. Arch Gynecol Obstet. 2005;271(3):207-11. [PubMed ID: 15029506]. https://doi.org/10.1007/s00404-004-0600-7.
-
26.
Jahromi BN, Husseini Z. Pregnancy outcome at maternal age 40 and older. Taiwan J Obstet Gynecol. 2008;47(3):318-21. [PubMed ID: 18935996]. https://doi.org/10.1016/S1028-4559(08)60131-X.
-
27.
Luke B, Brown MB. Elevated risks of pregnancy complications and adverse outcomes with increasing maternal age. Hum Reprod. 2007;22(5):1264-72. [PubMed ID: 17289684]. https://doi.org/10.1093/humrep/del522.
-
28.
Jolly MC, Sebire N, Harris J, Robinson S, Regan L. Obstetric risks of pregnancy in women less than 18 years old. Obstet Gynecol. 2000;96(6):962-6. [PubMed ID: 11084186].
-
29.
Kale A, Kuyumcuoglu U, Guzel A. Is pregnancy over 45 with very high parity related with adverse maternal and fetal outcomes? Clin Exp Obstet Gynecol. 2009;36(2):120-2. [PubMed ID: 19688957].
-
30.
Moerman ML. Growth of the birth canal in adolescent girls. Am J Obstet Gynecol. 1982;143(5):528-32. [PubMed ID: 7091223].
-
31.
Plockinger B, Ulm MR, Chalubinski K, Schaller A. [When children "have children"--reproduction biological problems in girls between 11 and 15 years of age]. Geburtshilfe Frauenheilkd. 1996;56(5):248-51. [PubMed ID: 8768063]. https://doi.org/10.1055/s-2007-1022269.