The elderly primigravida is defined as a woman who gets pregnant for the first time at the age of 35 or more [1].

In the developed world and in developing countries in high socioeconomic group, the changing pattern of becoming pregnant at an advanced age can be attributed to various reasons. The reason could be changes in the structure of family with more late marriages or remarriages, women’s pursuit of higher education, carrier advancement, and advances in assisted reproductive technique and availability of effective and safe contraceptives. But in developing countries, the scenario is different in low socio economic group. The women tend to become pregnant at advanced age due to concept of large family size, sometimes desire for male child and moreover due to lack of knowledge of availability of effective contraception. Current evidence suggests a strong association with increased risk of miscarriage, chromosomal     abnormalities,      spontaneous    abortion, ectopic pregnancy, preterm delivery, prolonged labour, low birth weight, intrauterine fetal death, pregnancy induced hypertension and gestational diabetes [2]. 

Traditionally, elderly gravida is considered to be a high-risk pregnancy having an increased probability of complications. With the help of advanced technology, the risk has been reduced significantly and many studies have been done to know the actual risk of elderly gravida as compared to a younger pregnant woman [3].

Medical risks are related to an ageing reproductive system and may be associated with pregnancy complications like hypertension, GDM, and IUGR and many more. There are increased risks of different chromosomal and some genetic abnormalities in the baby of women with advanced maternal age are also high [4].

The purpose of this study was to determine the Antenatal and obstetrics complications in elderly gravida which would help us subsequently, in delineating the management of elderly gravida which would include pre-conceptional counselling, prenatal diagnosis followed by antenatal, intrapartum and postpartum management.

Aims and Objectives

• To assess the Antenatal and obstetrics complications in elderly gravida in tertiary care hospital.

• To assess the maternal and gynaecological complications in elderly gravida in tertiary care hospital.

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 one year period from 1st July 2018 to 30^th 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.

Data collection

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.  A detailed history of pre existing medical conditions such as pre-gestational diabetes, cardiac disease, chronic hypertension, renal disease, thyroid disease, seizure disorders, psychiatric disorders were taken. History of using medication before conception such as insulin, cardiac medicines, antipsychotic, and thyroid medication was asked. 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 1 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 from1^st July 2018 to 30^th 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).

Table 1: Age Distribution in Study and Control Group.

It was observed that the total number of complications in the study group was 270(65.06%) and in the control group were 126(30.36%). It was observed that 81(19.52%) and 42(10.12%) subjects respectively in the study and control group had anaemia. The p value was significant (0.00001). Pre-eclampsia was seen in 18(4.34%) subjects in the study and 9(2.17%) in the control group respectively. The p value was not significant (0.07) Hypothyroidism was seen in 30(7.23%) subjects in the study group and 48(11.57%) in the control group. The p value was significant (0.03) Gestational hypertension was seen in 75(18.07%) subjects in the study group and 9(2.17%) in the control group. The p value was significant (0.00001) Diabetes mellitus was seen in 21(5.06%) subjects in the study group and 3(0.72%) subjects in the control group. The p value was significant (0.00001) Eclampsia was seen in 3(0.72%) both in the study and control group. Cholestasis was seen in 9(2.17%) subjects in the study group and 6(1.45%) subjects in the control group. Hepatitis was seen in 6(1.45%) subjects in the study and none in the control group. 6(1.45%) subjects in the study group and none in the control group had epilepsy. Incidence of medical disorders in study group is much more as compared to control group (Table 2).

Table 2: Antenatal Medical Complications

It was observed that Gynecological complications in the study group were 11(2.65%) and in the control group were 9(2.17%). Out of 415 subjects in both study and control group 9(2.17%) and 3(0.72%) had fibroid uterus respectively. The p value was not significant (0.08). In the study group bicornuate uterus were present in 2(0.48%) subjects. None was present in the control group.None of the subjects in study group had ovarian cyst while 6(1.45%) in control group had ovarian cyst. The p value was significant (<0.05) (Table 3).

Table 3: Gynecological Complications

It was observed that out of 415 subjects in both study and control group 155(37.35%) and 161(38.80%) had intrauterine growth restriction respectively. The p value was not significant (0.66). 27(6.50%) and 18(4.34%) subjects had breech presentation in the study and control group respectively. The p value was not significant (0.17). Congenital malformations of fetus were seen in 5(1.20%) subjects in the study group and 2(0.48%) subjects in the control group. The p value was not significant (0.25). Intrauterine death of fetus was seen in 3(0.72%) subjects in both study and control group. The p value was not significant (1). Twin pregnancy was seen in 9(2.17%) subjects in study group and none in the control group. The p value was significant (<0.05). Abruptio placenta was seen in 15(3.61%) subjects in the study group and 3(0.72%) subjects in the control group. The p value was significant (0.004). Placenta previa was present in 6(1.45%) subjects in both study and control groups. The p value was not significant (1). Fetal complications like breech and congenital malformations were more common in the elderly women (Table 4).

Table 4: Fetal & Placental Complications

It was observed that out of 415 subjects there were 21(5.06%) cases of PPH in study group and none in control group. The p value was significant (<0.05). There were no cases of retained placenta or maternal mortality encountered during the course of study (Table 5).

Table 5: Maternal Complications

A prospective controlled 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. 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 1^st July 2018 to 30^th 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. [6], 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.

In the present study anaemia was observed in 19.52% subjects in the study group. The incidence was comparable to the study conducted by Verma et al. [7] (23.90%) and the study by Moses et al. [8]. Elderly multigravida are more ignorant about their health hence more prone to nutritional deficiencies and anaemia.

In the present study, 7.23% subjects had hypothyroidism in the study group. In the study by Verma et al. [7], hypothyroidism was observed in comparable number of patients. Present study was conducted in Himachal Pradesh, which is a part of sub- Himalayan belt where goiter is endemic. 

In the present study 22.41% subjects in the study group had pregnancy induced hypertension. It was comparable to the study conducted by Pawde et al. [6] (17.54%) and the study conducted by Giri et al. [5] (26.60%). In women with advanced maternal age, there is increased incidence of pre-existing essential hypertension contributing to higher incidence of hypertensive disorders. Also with increasing age, there are changes in cardiovascular profile of patient and increased levels of stress and anxiety.

In the present study 5.06% subjects had diabetes mellitus in the study group. Diabetes mellitus was present in higher proportion in women in study by Pawde et al. [6] (10.52%) because this study was conducted on patients booked at the hospital while present study was conducted on patients admitted in labor room, mainly consisting of patients booked or referred from peripheral health institutions. There is abnormal glucose tolerance with increase in age as the advancing age and Weight again cause insulin resistance and diabetes mellitus.

In the present study 0.72% subjects had eclampsia in both study group. It was comparable to the study conducted by Verma [7] (1.8%). According to NITI Aayog report on Health Index June 2019, Himachal Pradesh ranks among top 5 states in the country. Since there are better health facilities, hence the incidence of eclampsia is less. This study was conducted at Kamla Nehru State Hospital for Mother and Child which is a tertiary care institute receiving high risk referral cases from all over the state. In women with advanced maternal age, there was increased incidence of pre-existing hypertension contributing to hypertensive disorders.

In the present study 37.35% subjects in the study group had intrauterine growth restriction. It was higher as compared to study conducted by Sahu et al. [9] (8.9%) and Moses et al. [8] (22%). In present study, majority of patients belong to rural setup with socioeconomic class 4. Due to low socio-economic status and poor nutrition, incidence of IUGR is higher. There are better health services in Himachal Pradesh, better antenatal booking leads to detection of more cases of IUGR. With advancing age, the incidence of medical complications like essential hypertension, pregnancy induced hypertension, anaemia increase leading to reduced utero-placental blood flow leading to intrauterine growth restriction.

In the present study 6.50% subjects had fetal mal-presentations in the study group. It was comparable to the study conducted by Sahu et al. [9] (5.90%) and Ramachandran et al. [10]. With advancing maternal age, the incidence of fibroid uterus and placenta praevia increases which contribute to the increased incidence of fetal mal-presentations in the elderly.

In the present study multiple pregnancies was observed in 2.17% subjects in the study group. The incidence of multiple pregnancies was comparable in study conducted by Sahu et al. [9] (5.20%). Fertility decreases with increasing age. Some subjects in the study group had received treatment for infertility and conceived on ovulation induction drugs. Some women conceived after in vitro fertilization techniques. This led to increase in incidence of multiple pregnancy in elderly subjects.

In the present study congenital malformations were observed in 1.20% subjects in study group. The incidence of congenital malformations was more in the study conducted by Sahu TM et al. [9] (3.3%). Owing to better health facilities in Himachal Pradesh, congenital malformations were detected earlier and managed accordingly. The risk of congenital malformations increases significantly with age. Chromosomal and structural abnormalities increases with age. In older women aged oocytes are more susceptible to aneuploidy and other chromosomal abnormalities. Pre-conceptional use of folic acid has been associated with decrease in incidence of congenital anomalies.

In the present study intrauterine death was seen in 0.72% subjects in both the groups. The p value was not significant. It was less than that of Moses et al. [8] (2%). The congenital malformations and maternal medical complications increase significantly with age which contribute to increase in number of intrauterine deaths. Also access to better antenatal screening in Himachal Pradesh, makes it possible for early detection of congenital anomalies and their appropriate management.

In the present study 5.06% subjects had ante partum hemorrhage in the study group. In the study conducted by Sahu et al. [9] and Verma [7] the incidence of ante partum hemorrhage was comparable to the present study. With advancing maternal age medical complications like anaemia, pregnancy induced hypertension, abnormal placentation increases. Other factors like low socioeconomic status, poor nutrition, and fibroid uterus also increase the risk of ante partum hemorrhage.

In the present study fibroid uterus was seen in 2.17% subjects in the study group. It was comparable to studies conducted by Shehade [11] (2.9%). Fibroid is a benign neoplasm with highest incidence between 30-40 years of age.

In the present study 5.06% subjects had retained placenta in study group. The incidence was less in the study by Ziadeh et al. [12] (2.8%) because their study was restricted to primigravida while present study included mostly multigravida. The prevalence of anaemia is also more in present study which predisposes a patient to post partum hemorrhage.

The incidence of anaemia in the present study was 18.91% and 22.73% in the age group 35-39 years and >40 years respectively. The incidence was comparable in >40 years age group in the present study (22.73%) as compared to study conducted by Orji et al [13] (19.3%). This may be because of low socioeconomic status, low literacy levels and lack of access to adequate antenatal services. 

The incidence of pregnancy induced hypertension was 18.05% in the age group 35-39 years and 22.73% in >40 years group in the present study which was more than other studies. This may be because of higher incidence of gestational hypertension in the present study.

The incidence of diabetes mellitus was 2.58% in 35- 39years age group in the present study. It was more than other studies. The incidence in >40 years age group was 18.18% in the present study which was higher than other studies. This was because of the higher incidence of diabetes mellitus in northern India where this study was conducted.

Advanced maternal age has been associated with an increased risk of various complications like hypertension, diabetes, and intrauterine growth retardation and congenital malformations. Elderly garvida are considered as high risk pregnancy and they need special attention and care during pregnancy and child birth. By knowing and understanding the risk of complications, we expect to establish better standards in practice. Timely and accurately diagnosis of complications and their treatment leads to favorable outcome.

Elderly women are at a high risk of several complications including instrumental deliveries, mal-presentations, mal-positions, prolonged labor, increased caesarean  section   rate,   induction   of   labor,  pregnancy induced hypertension, diabetes mellitus, ante and post partum haemorrhage. Fetal pregnancy outcomes such as, Oligohydramnios, Breach and Transverse lie were found significantly more in elderly primigravida.

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