Introduction
Age is one of the important determining factor of the outcome of pregnancy. Either in spectrum is associated with the adverse outcome. As the age increases maternal medical and obstetrical complications rises. In 1958 the council of the International Federation of Obstetricians and Gynaecologists adopted a definitions specifying the elderly primigravida as one aged 35 or more at first delivery.1 The study involving 2560 deliveries in India have showed the incidence to be 7%.2 Elderly primigravida is associated with obstetrical complications like abnormal presentation, malpresentation, instrumental deliveries, antepartum and postpartum hemorrhage, hypertension, cephalopelvic disproportion and diabetes mellitus. The associated complication results in increased in caesarean section rate. The increase incidence of underlying medical diseases, decreased cardiovascular reserve and diminished ability to adapt to physical stress that may accompany aging would combine to increase adverse outcome.3 As the standard of living increases, delayed marriage, in pursuit of job, women tend to delay marriage and hence pregnancy. The artificial reproductive technology have opened an opportunity to parenthood even at the advanced age. The outcome of pregnancy in relation to maternal age is different in women whose pregnancy is naturally conceived, compared to those who is conceived by assisted reproductive technology.4
Materials and Methods
The study was conducted in Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences, Imphal from 1st October 2011-April 2013.
A total of 166 Elderly Primigravida admitted in Department of Obstetrics and Gynecology were enrolled in the study after taking the informed consent.
Elderly Primigravida with preexisting medical condition like Hypertension, Diabetes, Asthma and those unwilling to participate in the study was excluded from study.
On admission the detail history and examination was done. The blood samples were collected for routine examination. Obstetric ultrasound was done for growth and placental localisation. Data of patient and pregnancy termination details was recorded in performa.
Results and Observations
The study was conducted from 1st October 2011-April 2013. During the period there were 17890 deliveries of which 280 was elderly primigravida giving an incidence of 1.8%. 166 Elderly primigravida was enrolled to study foetal maternal outcome based on inclusion criteria.
Socio-demography
Religion
Majority of the elderly primigravida were from Hindu (98.2%), few from Christian (1.8%) and none from Muslim as shown in Table 2.
Occupation
Majority of the elderly primigravida were housewife which accounted for 84.3% of cases followed by teacher (6.6%) as shown in Table 3.
Table 3
Distribution of respondents based on occupation
Educational level
Class X standard and below constituted most common (38.5%) education level for elderly primigravida followed by graduate and above (32.7%) as shown in Table 4.
Socio-economic status (SES)
Majority of the cases were from middle socio economic class which accounts for 83.8% of cases as shown in Table 5.
Booked status
Most of the respondents were booked which accounts for 94.6% of cases as shown in Table 6.
Period of gestation
Most of the cases were termed (93.4%), few were preterm (3%) and few (3.6%) were post term as shown in Table 7.
Table 7
Distribution of respondents based on period of gestation
| POG | Number of cases | Percentage |
| <37 weeks | 5 | 3.0 |
| 37-40 weeks | 155 | 93.4 |
| >40 weeks | 6 | 3.6 |
| Total | 166 | 100.0 |
Table 8
Distribution of respondent based upon the antenatal complication
Maternal outcome
Mode of delivery (MOD)
Majority of the elderly primigravida cases were delivered by LSCS which accounted for two third of cases.
Table 9
Distribution of respondents based on mode of delivery
| Mode of delivery | Number of cases | Percentage |
| Vaginal | 54 | 32.5 |
| LSCS | 112 | 67.5 |
| Total | 166 | 100.0 |
Table 10
Distribution of respondents based on reasons for doing LSCS in elderly primigravida
| Reasons for LSCS | Number of cases | Percentage |
| Cephalo-pelvic disproportion | 70 | 62.5 |
| Oligohydramnios | 10 | 8.9 |
| Breech | 8 | 7.1 |
| PIH | 5 | 4.4 |
| Placenta preavia | 4 | 3.5 |
| Others* | 15 | 13.9 |
| Total | 112 | 100.0 |
The main reason for doing LSCS in elderly primigravida was cephalo-pelvic disproportion (62.5%) followed by oligohydramnios (8.9%).
Maternal complications
Table 11
Distribution of respondents based on complications during delivery
| Maternal complications | Number of cases | Percentage |
| Yes | 0 | 0.0 |
| No | 166 | 100.0 |
| Total | 166 | 100.0 |
There was no maternal complication detected in the study.
Fetal outcome
Table 12
Distribution of respondents based on sex of the baby in elderly primigravida
| Sex | Number of cases | Percentage |
| Male | 82 | 48.3 |
| Female | 88 | 51.7 |
| Total | 170 | 100.0 |
Little more than half of the babies were females (51 7%)
Table 13
Distribution of respondents based on sex of the baby in elderly primigravida
| Agpar score | Number of cases | Percentage |
| Score of 7 | 5 | 3.0 |
| Score of 8 | 13 | 7.8 |
| Score of 9 | 148 | 89.2 |
| Total | 166 | 100.0 |
Most babies had a apgar score of 9 (excluding 2nd baby of twins) which accounted for 89.2% as shown in Table 10.
Table 14
Distribution of respondents based on weight of the baby in elderly primigravida
| Weight in Kg | Number of cases | Percentage |
| <2.5 | 9 | 5.3 |
| 2.5-4 | 156 | 91.8 |
| >4 | 5 | 2.9 |
| Total | 170 | 100.0 |
Majority of the babies weighted 2.5 to 4kg which accounted for 91.8% and few had weight less than 2.5 (5.3%).
Discussion
The impact that the decision to delay childbearing has on maternal and perinatal outcomes have become increasingly relevant as more and more women postpone having children until they are over the age of 35year. The study was carried out in Regional institute of medical sciences (RIMS) to find out the outcome in those group of women. The incidence of elderly primigravida in RIMS was 1.8% which was similar to study conducted by Ojule et al.5 of 1.4%. The lower incidence might be due to increasing rates of abortion that had lead to pregnancy loss before viability or due to reduced access to hospital care. Most of the patients had undergone abortion or miscarriage by the time they reach 35year. Among elderly primigravida 41% belonged to age group of 35year, 54.8% were of 36-40 years and 4.2% >40year.
Religion itself has an influence in the age of marriage. 98.2% were Hindu (meetei) where there is a cultural practice of late marriage, 1.8% was Christian, whereas in this study no Muslim elderly primigravida was recorded.
Despite 38.5% were educated up to 10th standard, 32.7% graduate and above, 84.3% was housewife or not working in contrast to study by Marai et al.6 where 65% was housewife and 45% was educated till 12th standard. Whether the pregnancy was as a result of delayed childbearing in pursuit of goals or delayed conception with period of subfertility, further study has to be undertaken.
Initially elderly primigravida was considered among the well to do class Benjamin et al7 in this study 83.8% belonged to middle class, 11.4% to lower and 4.8% to upper class, indicating there is change in attitude toward late conception due to better obstetric care and it increasing prevalence in all the socio-economic strata.
94.6% of elderly primigravida was admitted as a booked case in RIMS with regular antenatal checkup, which is higher in comparision to study by Eke et al.8 where 68.6% of elderly primigravida was booked. The earlier diagnosis of complication results in optimal management and fetomaternal outcomes.
An interesting aspect of this study was that the advancing maternal age was not significantly associated with the hypertensive complication of pregnancy. The occurrence of hypertensive complication in this study was 3.01%, this is in contrast to other studies where the hypertensive diseases were more frequent. This study have a result similar to study by Jane et al.9 where there was no statistically significant occurence of hypertensive disorder of pregnancy. Other pregnancy related complications were oligohydraminos (6.02%), PROM (4.2%), placenta praevia (2.4%), gestational diabetes (0.6%), uterine leiomyoma (3.6%), polyhydraminos (1.8%), twin (1.8%), transverse lie (0.6%), breech (2.4%) and anemia (l1.2%) which was similar to study undertaken by Marai et al.6
Over years studies have shown the increase in incidence of preterm and postterm delivery among elderly primigravida. In the study by Jane et al.9 the incidence of preterm was 5.2%, in our study 3% delivered preterm, before 37week, 93.4% between 37-40 week and 3.6% after 40week. This conflicting result might be due to management of all elderly primi as a high risk with intensive monitoring during antenatal visit and with frequent admission in hospital before term for safe confinement.
As with other study 67.5% of elderly primigravida was delivered by caesarean section which was similar to study by vercellini et al.10 where the incidence was 64%. Among those who delivered vaginally 1.8% needed instrumentation. There was two assisted vaginal breech delivery. The most common indication for caesarean section was cephalopelvic disproportion in 62.5%, followed by oligohydraminos in 8.9%, for Breech was 7.1%, for placenta praevia in 3.5% and others like for twins, transverse lie, non progress of labour, postdated pregnancy constituted 13.9%. Majority of caesarean sections was elective. Those who delivered vaginally were usually in active labour. Eke et al found that the most common indication of ceasarean section was cephalopelvic disproportion in 15.9% followed by fetal distress in 4.9%. Similarly Sivalingam et al.1 reported the commonest indication to be prolonged labour in 38.7% followed by preeclampsia in 20.4%, breech in 12.2% and placenta praevia in 2.04%.
There was no postpartum complication either following caesarean or Vaginal delivery in our study. Oboro et al.11 noted postpartum hemorrhage in 4% and retained placenta in 6.4% of cases. The trend of considering the elderly primi as a high risk had lead to prophylactic intervention to prevent complications in postpartum period.
Among 170 babies born, 51.7% were female. The incidence of low birth weight babies were 5.3% while 2.9% had a birth weight of >4kg which is similar to study by Marai et al.6 where the 13% babies had a low birth weight and 5% was macrosomic. The APGAR score of <7 at birth was present in 3% of cases while maximum of the babies, in 89.2% APGAR score was 9. This in comparision to findings of study by Sahu et al.2 where APGAR score of <7 at 5minute was seen in 13.5%. The initial resuscitative measure as well as presence of skilled personel during delivery plays a key role in reduction of perinatal morbidity. In this study two babies needed admission into NICU because of prematurity and low APGAR score, however there was no perinatal death.
Conclusion
The elderly primigravida remains at high risk with unpredictable pregnancy outcome. In our study majority of women delivered at term without maternal and perinatal adverse outcomes. Advancing age did not appeared to be associated with hypertensive complications. Nonetheless as age increases, they become prone to obstetric complications along with medical complications concomitant with aging. The caesarean rates was high whether as a result of obstetric indication or considering age factor as an indication, have to be reviewed. Although the likelihood of complications increases with the age, patients can be reassured that overall maternal and fetal outcomes are favorable with regular antenatal, emergency obstetric care and skilled personnel during labor.
