Key findings:

The key findings of the study include a higher incidence of elderly gravida (age 35 or older) comprising 6% of deliveries, with a majority between 35-39 years. Elderly gravida exhibited higher multiparity, lower primiparity, and a significant history of infertility. Additionally, they had increased use of assisted reproductive techniques and higher rates of ectopic pregnancy and abortion compared to younger controls.

What is known and what is new?

The abstract discusses a prospective study assessing infertility and early pregnancy outcomes among elderly gravida (age 35 or above) compared to a control group (age 20 to <35). Known factors such as decline in fertility with age are highlighted, while new findings include higher incidence of infertility history, assisted reproductive technique use, ectopic pregnancy, and abortion among elderly gravida.

What is the implication, and what should change now?
The abstract highlights the increased risk of infertility, assisted reproductive technique use, ectopic pregnancy, and abortion among elderly gravida compared to younger controls. Clinicians should prioritize comprehensive care and early intervention for elderly gravida to mitigate these risks and improve pregnancy outcomes. Vigilance in addressing age-related fertility challenges is imperative for effective infertility treatment.
 

INTRODUCTION

Maternal age affects pregnancy from conception to delivery. The women today have a greater control over their reproductive lives than before and the trend of postponing the motherhood has become common in last 2-3 decades1. In developing countries, like India, there exists the concept of large family size, patriarchal society with desire for male child and lack of knowledge and availability of proper contraception. While in developed countries, there exists trends of higher education, career oriented females, easy availability and knowledge of effective contraceptive methods leading to late marriage and hence delayed childbearing [1]. 

There are two groups of elderly primigravida: One with high fecundity- women married late but conceives soon after marriage. One with low fecundity- women married early but conceives long after marriage [2].

In the developed world, deferment of marriage and postponement of child-bearing in marriage are resulting in unprecedented numbers of couples who desire pregnancy relatively late in life. These factors combine with a decline in fertility and an increase in pregnancy wastage with advancing age to present new challenges for the clinician treating infertility [3].

Fertility declines with age and the risk of miscarriages,       ectopic        pregnancies,     chromosomal abnormalities, and increases of congenital anomalies. Studies have been conducted globally to analyze the effects of advanced maternal age on pregnancy outcome [4].

The purpose of this study was to assess the Infertility and Early Pregnancy Outcome among Elderly Gravida which would help us subsequently, in delineating the management of elderly gravida.

• To assess the infertility among elderly gravida in tertiary care hospital.

• To assess the Early Pregnancy Outcome among Elderly Gravida. 

This prospective study was carried out in the  department of Obstetrics and Gynaecology at Kamla Nehru State Hospital for Mother and Child, Indira  Gandhi Medical College, Shimla for a one year period  from 1st July 2018 to 30th June 2019.  
Selection Of Patients: 

All participants were divided into two groups: 

Group1 (Study Group)- 
•  All pregnant women with age 35 years or more. 
•  Patient admitted in labor room.  
•  Women consenting for participation in the study. 

Group 2(Control Group)- 
•  Every pregnant woman with age ≥20 to ˂35 years, who gets enrolled in the labor room admission register next to a case, was taken as a control. 
 

Written consent was taken and counseling about the study was done of the women willing to participate in the study. Confirmation of pregnancy was done. History of infertility, assisted conception such as ovulation induction or artificial reproductive techniques and early pregnancy outcomes were inquired. Comparative data of the two groups was subjected to statistical analysis.  
 

A prospective study was conducted in the department of Obstetrics and Gynaecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College,  Shimla, to study the pregnancy outcome at maternal age 35 years and older. Group consisted of 415 subjects >35 years of age and Group 2 consisted of 415 subjects 20-34years of age delivering in this hospital during one year period from1st July 2018 to 30th June 2019. 

There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older.

It was observed that out of 415 subjects in the study group, 349(84.10%) were in the age group of 35-39 years and 66(15.90%) were in the age group of 40 years and above. The oldest patient was 44 years old. Mean age was 37.80+1.83 years. In the control group subjects were in the age group of 20-34years of age. It was observed that out of 415 subjects in the control group, 117(42.65%) were in the age group of 20-24 years, 148(35.66%) were in the age group of 25- 29 years and 90 (21.69%) were in the age group of 30- 34 years (Table 1). 

It was observed that out of 415 subjects in both study and control group 36(8.67%) and 284(68.43%) were primipara respectively with statistically significant p-value (0.00001). 172(41.45%) were second paras in the study group and 110(26.51%) in the control group. 138(33.25%) and 18(4.34%) subjects were third paras in the study and control group respectively. 69(16.63%) and 3(0.72%) were grand-multiparas in the study and control group respectively. The numbers of grand multiparas were more in the study group (16.63%) and primiparas were more in control group (0.72%) (Table 2).

It was observed that out of 415 subjects in both the study and control group 36(8.67%) and 284(68.43%) subjects were primiparas 3(8.33%) and 196(69.02%) subjects were married for less than 1 year in study and control group respectively. The p-value was significant (0.00001). 12(33.33%) and 54(19.01%) subjects were married for 2-3 years in study and control group respectively with significant p-value (0.045). 11(30.56%) and 24(8.45%) were married for 3-4 years in study and control group respectively with significant p-value (0.00006). 10(27.78%) and 10(3.52%) subjects were married for more than 4 years in study and control group respectively. The p-value was significant (0.00001) (Table-3).

History of infertility was present in 8.67% subjects in the study and 2.17% subjects in the control group which was statistically significant (<0.001). Out of these 9(25%) had history of intake of ovulation inducing drugs in the study group and 9(2.17%) in the control group. The p-value was significant (<0.001). 21(58.33%) conceived with use of in vitro fertilization techniques in the study group and none in the control group with significant p-value (<0.05). 6(16.67%) subjects conceived spontaneously in study group and none in control group with p-value (>0.05). It was observed that with increasing age fertility decreases. More subjects require assisted reproductive techniques (Table 3). 

It was observed that out of 415 subjects both in study and control  group,   ectopic   pregnancy   was   present  in 39 (9.40%) subjects in study group and 9(2.17%) subjects in control group. The p-value was significant (0.00001). In the present study, 48(11.57%) subjects had abortion in the study group and 12(2.89%) subjects had abortion in control group. The p-value was significant (0.00001) (Table 4).

Table 1: Age Distribution in Study and Control Group

Table 2: Parity and Booking Status in Study and Control Group

Table 3: Infertility Assessment in Primiparas

Table 4: Early Pregnancy Outcome

A prospective controlled study was conducted in the department of obstetrics and gynecology, Kamla Nehru State Hospital for Mother and Child, Indira Gandhi Medical College, Shimla, to study the pregnancy outcome at maternal age 35 years and older. Study group consisted of 415 subjects >35 years of age and control group consisted of 415 subjects 20-34 years of age delivering in this hospital during one year period from 1st July 2018 to 30th June 2019. There were 6922 deliveries during this period, out of which 415 (6.00%) were in the age group 35 years and older. 

In the present study the percentage of pregnant women aged > 35 years was 6.00% In the studies conducted by Giri et al. [5] and Pawde et al. [4], the percentage was 4.53% and 9.63% respectively. The present study was conducted in Himachal Pradesh. Most of the women complete their family by the age of 24-25 years. 

It was observed that out of 415 subjects the study group 36(8.67%) were primipara which was less than in the study done by Ramachandran et al. [6] and Dixit and Madhuri [7]. There were 379 (91.33%) multiparous subjects in study group. There is a less number of elderly primigravida. Elderly gravida are mostly multigravida The number of grand multiparas were more in the study group (16.63%). The cause for more number of multigravida is ignorance, lesser knowledge of contraceptive measures and desire for a male child. The sample size of the studies conducted by Ramachandran et al. [6] and Dixit and Madhuri [7] was too small as compared to present study.

In the present study, abortions and ectopic pregnancy were observed in 20.97% and study group. The incidence was comparable with the study by Pawde et al. [4] (18.90%) which was comparable. Most of the abortions were first trimester abortions. Chromosomal and structural abnormalities increase with age. Preconceptional counseling of elderly women regarding the increased risk of abortions must be done.

In the present study 8.67% subjects had history of infertility in the study group. It was less as compared to study conducted by Ramachandran et al. [6] (14.29%). With advancing age fertility decreases, oocyte reserve is less and stress and anxiety increases. All these lead to increased incidence of infertility and ART.

In the present study there were 3.44% and 36.36% subjects in the age group 35-39 years and >40 years with history of infertility and ART. It was higher than study by Cleary-Goldman et al. [8] (8.3% and 18.70% in 35-39 and >40 years respectively). The present study was conducted in Himachal Pradesh where most of the women complete their families by the age of 24-25 years. Women who are >40 years mostly present with infertility and require some form of ART.

History of infertility, Use of assisted reproductive techniques, ectopic pregnancy and history of abortion was significantly more in Elderly Gravida as compared to control group. Advancement in artificial reproductive technologies have further made it possible for the women of advanced age to achieve pregnancy.

Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College, Shimla.
 

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