Neonatal Outcome of Babies Born to Women 40 Years and over at the University Hospital of the West Indies 2012–2013

Neonatal Outcome of Babies Born to Women 40 Years and over at the University Hospital of the... Abstract Aim This article aims to determine neonatal outcome of babies born to women ≥40 years at the University Hospital of the West Indies. Methods This was a matched retrospective cohort study looking at the outcome of all babies born to women ≥40 years and control babies born to women aged 20–30 years at the University Hospital of the West Indies over a 2-year period. Maternal and neonatal demographic data and course of admission for admitted neonates were recorded. Descriptive analyses were performed. Results One hundred and ninety-eight neonates were born to women ≥40 years and 208 to their younger counterparts, M:F 1:1.2. There was no difference in the number of preterm or low birth weight infants, the number of neonates with a low 5 min Apgar score <7, the number of neonates admitted or the number of neonates who died between women ≥40 years and their younger counterparts (p > 0.05). Conclusion No difference in adverse neonatal outcome was noted between women ≥40 years and their younger counterparts. INTRODUCTION Increased access to educational opportunities has led to women delaying the onset of child bearing, resulting in more women having children at an advanced age. Current literature is divided on the neonatal outcome of babies born to women ≥40 years. Some researchers have found that although there is an increased incidence of maternal morbidities such as hypertension, diabetes and operative delivery, this does not adversely affect neonatal outcome [1, 2]. Other researchers, however, cite an increased incidence of morbidities in neonates born to women ≥40 years, such as low birth weight, prematurity, small for gestational age, large for gestational age, macrosomia, increased admission to the neonatal unit, low 5 min Apgar score <7 and adverse foetal and perinatal outcome [3–19]. With a greater number of women worldwide delaying the age of first pregnancy, it can be anticipated that with time Jamaica also will experience an increase in the number of women ≥40 years who will deliver babies. Owing to the dearth of information on the neonatal outcome of babies born to women ≥40 years in Jamaica and the English-speaking Caribbean, the documentation of the neonatal outcome among women ≥40 years is of paramount importance. This study aimed to determine neonatal outcome of babies born to women ≥40 years at the University Hospital of the West Indies (UHWI). METHODS This was a matched retrospective cohort study looking at the outcome of all babies born to women ≥40 years and control babies born to women aged 20–30 years at the UHWI over a 2-year period. POPULATION All women aged ≥40 years who delivered a singleton live baby at the UHWI between 1 January 2012 and 31 December 2013 were included in this study. A control woman aged 20–30 years who delivered a singleton live baby nearest in time following the index case within a 24 h period was also included in the study. PROCEDURE Cases and controls were identified from the labour ward admission book. Maternal demographic data (age, gravidity, parity, mode of delivery, chronic illness) and neonatal demographic data (birth weight, gestational age if premature, Apgar score) were recorded. Babies admitted to the neonatal unit from the labour ward or the postnatal ward/home were identified from the neonatal unit admission book. Dockets of all babies admitted to the neonatal unit were reviewed and data on reason for admission, interventions, duration of stay and outcome of admission were recorded using a data extraction sheet. Outcome measures were preterm birth, low birth weight, low 5 min Apgar score <7, admission to the neonatal unit and neonatal death. Ninety-eight percent (100/102) of dockets were available for review. DEFINITIONS A preterm infant was defined as one delivered before 37 completed weeks of gestation. A low birth weight infant was defined as any neonate whose birthweight was <2500 g. A small for gestational infant was defined as any neonate whose birthweight was <10th percentile on the World Health Organization growth charts for term infants and the Fenton preterm growth charts for preterm infants. DATA ANALYSIS Descriptive analyses were performed. Analysis of differences between babies born to women ≥40 years and those born to women 20–30 years was performed using the student t test for continuous variables and the Chi-squared test for categorical variables. Statistical significance was taken at the level p < 0.05. Statistical analyses were performed using Statistical Package for the Social Sciences version 14 (SPSS Inc., Chicago, IL). ETHICAL APPROVAL Ethical approval for the conduct of this study was granted by the University of the West Indies Mona Research Ethics Committee. RESULTS Four hundred and six women fulfilled inclusion criteria for this study: 198 were women ≥40 years and 208 women were 20–30 years. The mean maternal age was 41.5 ± 1.7 years and 25.1 ± 2.6 years for the older women and their younger counterparts, respectively. There were 181 (91%) multigravid women ≥40 years compared with 109 (52%) mutigravid women in the younger group. Older women were more likely to have a chronic illness (hypertensive disorders in pregnancy and diabetes) than their younger counterparts (OR: 3.0; CI: 1.8–4.7). Women ≥40 years (108; 55%) were also more likely to be delivered via caesarean section than their younger counterparts (56; 27%) (OR: 3.1; CI: 2.1–4.8). Women ≥40 years accounted for 50 of 68 (74%) of the elective caesarean sections and 59 of 97 (61%) of the emergency sections performed, p < 0.001. The major reasons for emergency sections in the older women were foetal jeopardy (31%), failure to progress (23%), severe pre-eclampsia (13%) and a history of previous caesarean section in active labour (13%). Four hundred and six neonates were born to women in the study, M:F 1:1.2. There were 198 neonates delivered to women ≥40 years and 208 delivered to their younger counterparts. There was no significant difference in mean birth weight, gestational age and 1 and 5 min Apgar scores between neonates born to women ≥40 years and those born to their younger counterparts (Table 1). Similarly, there was no difference in these variables between neonates born to primigravid women ≥40 years and their younger primigravid counterparts, or multigravid women ≥40 years and their younger multigravida counterparts (p > 0.05). Among women ≥40 years, there was no difference in these variables between babies born to primigravida and multigravida women (p > 0.05). Table 1 Demographics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Table 1 Demographics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 A greater proportion of preterm, low birth weight and very low birth weight infants were born to women ≥40 years; however, this did not reach statistical significance (p > 0.05) (Table 2). There was also no difference in the number of preterm and low birth weight infants between primigravida older and younger women. However, multigravid women ≥40 years were more likely to deliver a Low birth weight (LBW) infant (32; 17%) than their multigravid younger counterparts (10; 9%) (OR: 2.1; CI: 1.0–4.5). No difference in the number of preterm or low birth weight infants was noted between primigravid and multigravid women ≥40 years. There was also no difference in a low 5 min Apgar score < 7 between babies of older and younger women (p > 0.05). Table 2 Clinical characteristics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Table 2 Clinical characteristics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Ninety-two (23%) neonates were admitted to the neonatal unit, 45 (49%) from mothers ≥40 years and 47 (51%) from their younger counterparts (p = 0.5). Seventy-three percent of neonates born to women ≥40 years who required admission were admitted directly after birth compared with 57% of those born to younger women (p = 0.3). Twenty percent of neonates born to the older women were admitted from the post-natal ward compared with 30% for the younger women (p > 0.05). The main reasons for admission in both groups was presumed sepsis and neonatal jaundice. Seven percent of neonates born to women ≥40 years initially went home and then were subsequently admitted compared with 13% for their younger counterparts (p > 0.05). The main reasons for admission were presumed sepsis, neonatal jaundice and weight loss. There were no readmissions to the neonatal unit from either group. Neonates born to women 20–30 years who were admitted to the neonatal unit were more likely to have a sepsis screen performed, and those born to women ≥40 years were more likely to be treated for jaundice (Table 3). There were two babies with chromosomal abnormalities (trisomy 18 and 21) born to women ≥40 years during the study period. The median length of stay on the Neonatal Unit was 8 (interquartile range (IQR): 4–12.5) and 8 (IQR: 5.5–11) days for neonates born to women ≥40 years and their younger counterparts, respectively. Three neonates born to women ≥40 years died—two were extremely premature and one died from cardiac insufficiency. Similarly, three neonates born to women 20–30 years died, all of whom were extremely premature. Table 3 Morbidities of neonates admitted to the neonatal unit born to women ≥40 years and those born to women 20–30 years at the UHWI 2011–13 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Mechanical ventilation, synchronized intermittent mandatory ventilation via endotracheal tube; CPAP, continuous positive airway pressure; NNJ, neonatal jaundice. Table 3 Morbidities of neonates admitted to the neonatal unit born to women ≥40 years and those born to women 20–30 years at the UHWI 2011–13 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Mechanical ventilation, synchronized intermittent mandatory ventilation via endotracheal tube; CPAP, continuous positive airway pressure; NNJ, neonatal jaundice. DISCUSSION This study found that there was no difference in the delivery of a preterm or low birth weight infant between women ≥40 years and their younger counterparts. There was also no difference in the number of babies with low 5 min Apgar scores or in the number of neonatal admissions or deaths. In this study, women ≥40 years were no more likely to deliver a LBW infant than their younger counterparts; these findings are similar to that of Bianco et al. [1] and Wang et al. [2]. They however, differ from findings of studies from the UK [3], South Africa [5], Iran [20] and Turkey [21], where older women were found to be more likely to deliver a low birth weight infant. Similar to a study of Cameroon, we found that multigravid women aged ≥40 were more likely to deliver a LBW infant than their multigravid younger counterparts [16]. This increased frequency of LBW in the multigravida older women >40 years may reflect the interventions of the obstetricians and the increased occurrence of chronic illness such as the hypertensive diseases of pregnancy, which may affect utero placental function. This association has also been postulated by Gilbert et al. [22] in the USA. Primigravid older women, however, were at no increased risk of delivering a LBW infant when compared with their younger controls. We also did not demonstrate any difference by gravidity in the delivery of a LBW infant among older women, which is in contrast to Delpisheh et al. and Shaikh et al. who both found an increased incidence of LBW infants in primigravida women ≥40 years compared with multigravid women ≥40 years [3, 18]. This study did not find an increased occurrence of a low 5 min Apgar score <7 in neonates of older women in contrast to studies by Ates et al., Ngowa et al. and Cakmak Celik et al. [11, 16, 19]. This finding may be influenced by the increased number of older women who received an emergency caesarean section and may reflect timely intervention when foetal compromise is detected. Equal proportions of babies were admitted to the neonatal unit for the older and younger women. Neonatal morbidities during the course of admission were similar for the two groups except that babies born to the older women had an increased occurrence of neonatal jaundice. Also, babies born to the younger women had an increased rate of being screened for sepsis; again this is to be expected, as a greater proportion of them were admitted from home and a common reason for admission from home is to rule out sepsis. There was no significant difference noted in the length of stay for hospital admission. There were two babies with chromosomal abnormalities both born to the older women; this is not unexpected as the risk for chromosomal abnormalities increases with age. Women ≥40 years need to receive routine counselling about the risk of having a baby with chromosomal abnormalities. There were the same number of neonatal deaths in both groups and they were related to extreme prematurity. LIMITATIONS This was a retrospective chart review, as such data collection was limited to data already recorded. Another limitation to this study would be if any of the neonates after discharge from hospital presented to another health care facility for admission. We, however, believe this to be highly unlikely, as the mothers and their infants at UHWI usually return to the post-natal ward with their babies anytime up to 6 weeks of life if there is a problem. Although a greater proportion of babies born to women ≥40 years were preterm and low birth weight, this did not reach statistical significance; this finding may possibly be as a reflection of an inadequate sample size. RECOMMENDATIONS Women ≥40 years should be counselled about the increased risk of having an operative delivery and a baby with chromosomal abnormalities; they, however, can be reassured that they are at no greater risk for a poor neonatal outcome than their younger counterparts. CONCLUSION Although women ≥40 years were found to be at increased risk of having an operative delivery, no increased risk of adverse neonatal outcome was noted. REFERENCES 1 Bianco A , Stone J , Lynch L , et al. Pregnancy outcome at age 40 and older . Obstet Gynecol 1996 ; 87 : 917 – 22 . Google Scholar CrossRef Search ADS PubMed 2 Wang Y , Tanbo T , Abyholm T , et al. The impact of advanced maternal age and parity on obstetrics and perinatal outcomes in singleton gestations . Arch Gynecol Obstet 2011 ; 284 : 31 – 7 . Google Scholar CrossRef Search ADS PubMed 3 Delpisheh A , Brabin L , Attia E , et al. Pregnancy late in life: a hospital-based study of birth outcomes . J Womens Health 2008 ; 17 : 965 – 70 . Google Scholar CrossRef Search ADS 4 Kenny LC , Lavender T , McNamee R , et al. Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort . PLoS One 2013 ; 8 : e56583 . doi: 10.1371/journal.pone.0056583. Epub 2013 Feb 20. Google Scholar CrossRef Search ADS PubMed 5 Hoque ME. Advanced maternal age and outcomes of pregnancy: a retrospective study from South Africa . Biomed Res 2012 ; 23 : 281 – 5 . 6 Ludford I , Scheil W , Tucker G , et al. Pregnancy outcomes for nulliparous women of advanced age in South Australia, 1998-2008 . Aust N Z J Obstet Gynaecol 2012 ; 52 : 235 – 41 . Google Scholar CrossRef Search ADS PubMed 7 Valadan M , Tanha FD , Sephia A. Pregnancy outcomes in women of advanced maternal age . J Family Reprod Health 2011 ; 5 : 57 – 61 . 8 Berkowitz GS , Skovron ML , Lapinski RH , et al. Delayed childbearing and the outcome of pregnancy . N Engl J Med 1990 ; 322 : 659 – 64 . Google Scholar CrossRef Search ADS PubMed 9 Alberto VE , Marta LC , Olga GA , et al. Obstetric outcomes at advanced maternal age . J Gynaecol Obstet 2014 ; 2 : 7 – 11 . 10 Joseph KS , Allen AC , Dodds L , et al. The perinatal effects of delayed childbearing . Obstet Gynecol 2005 ; 105 : 1410 – 18 . Google Scholar CrossRef Search ADS PubMed 11 Ates S , Batmaz G , Sevket O , et al. Pregnancy outcome of multiparous women aged 40 years . Int J Reprod Med 2013 ; 2013 : 287519 . Doi: 10.1155/2013/287519. Epub 2012 Dec 29. Google Scholar CrossRef Search ADS PubMed 12 Baser E , Seckin KD , Erkilinc S , et al. The impact of parity on perinatal outcomes in the pregnancies complicated by advanced maternal age . J Turk Ger Gynecol Assoc 2013 ; 14 : 205 . Google Scholar CrossRef Search ADS PubMed 13 Andriantoky VB , Johannes RF , Vololonarivelo BE , et al. Late pregnancies outcomes: assessment of the obstetrical risks at the university hospital of the gynaecology and obstetrics, Befelatanana, Madagascar . Int J Reprod Contracept Obstet Gynecol 2014 ; 3 : 310 – 16 . Google Scholar CrossRef Search ADS 14 Lisonkova S , Janssen PA , Sheps SB , et al. The effect of maternal age on adverse birth outcomes: does parity matter . J Obstet Gynaecol Can 2010 ; 32 : 541 – 8 . Google Scholar CrossRef Search ADS PubMed 15 Mutz-Dehbalaie I , Scheier M , Jerabek-Klestil S , et al. Perinatal mortality and advanced maternal age . Gynecol Obstet Invest 2013 ; 1 : 50 – 7 . 16 Ngowa JDK , Ngassam AN , Dohbit JS , et al. Pregnancy outcome at advanced maternal age in a group of African women in two teaching hospitals in Yaounde, Cameroon . Pan Afr Med J 2013 ; 14 : 134 . doi:10.11604/pamj.2013.14.134.2315. Google Scholar PubMed 17 Canto MJ , Reus A , Cortes S , et al. Pregnancy outcomes in a Spanish population of women beyond age 40 delivered above 32 weeks gestation . J Matern Fetal Neonatal Med 2012 ; 25 : 461 – 6 . Google Scholar CrossRef Search ADS PubMed 18 Shaikh F , Wagan F , Jillani K , et al. Pregnancy outcome at maternal age 40 and older . J Liaquat Univ Med Health Sci 2012 ; 11 : 139 . 19 Cakmak Celik F , Aygun C , Kucukoduk S , et al. Maternal and neonatal outcomes in advanced maternal age: a retrospective cohort study . J Matern Fetal Neonatal Med 2016 ; 22 : 1 – 5 . 20 Jahromi BN , Husseini Z. Pregnancy outcome at maternal age 40 and older . Taiwan J Obstet Gynecol 2008 ; 47 : 318 – 21 . Google Scholar CrossRef Search ADS PubMed 21 Karat G , Dede FS , Tarcan A , et al. Pregnancy outcome in women aged 40 years and older . J Turk Ger Gynecol Assoc 2005 ; 6 : 114 – 17 . 22 Gilbert WM , Nesbitt TS , Danielsen B. Childbearing beyond age 40: pregnancy outcome in 24,032 cases . Obstet Gynecol 1999 ; 93 : 9 – 14 . Google Scholar PubMed © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Tropical Pediatrics Oxford University Press

Neonatal Outcome of Babies Born to Women 40 Years and over at the University Hospital of the West Indies 2012–2013

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Abstract

Abstract Aim This article aims to determine neonatal outcome of babies born to women ≥40 years at the University Hospital of the West Indies. Methods This was a matched retrospective cohort study looking at the outcome of all babies born to women ≥40 years and control babies born to women aged 20–30 years at the University Hospital of the West Indies over a 2-year period. Maternal and neonatal demographic data and course of admission for admitted neonates were recorded. Descriptive analyses were performed. Results One hundred and ninety-eight neonates were born to women ≥40 years and 208 to their younger counterparts, M:F 1:1.2. There was no difference in the number of preterm or low birth weight infants, the number of neonates with a low 5 min Apgar score <7, the number of neonates admitted or the number of neonates who died between women ≥40 years and their younger counterparts (p > 0.05). Conclusion No difference in adverse neonatal outcome was noted between women ≥40 years and their younger counterparts. INTRODUCTION Increased access to educational opportunities has led to women delaying the onset of child bearing, resulting in more women having children at an advanced age. Current literature is divided on the neonatal outcome of babies born to women ≥40 years. Some researchers have found that although there is an increased incidence of maternal morbidities such as hypertension, diabetes and operative delivery, this does not adversely affect neonatal outcome [1, 2]. Other researchers, however, cite an increased incidence of morbidities in neonates born to women ≥40 years, such as low birth weight, prematurity, small for gestational age, large for gestational age, macrosomia, increased admission to the neonatal unit, low 5 min Apgar score <7 and adverse foetal and perinatal outcome [3–19]. With a greater number of women worldwide delaying the age of first pregnancy, it can be anticipated that with time Jamaica also will experience an increase in the number of women ≥40 years who will deliver babies. Owing to the dearth of information on the neonatal outcome of babies born to women ≥40 years in Jamaica and the English-speaking Caribbean, the documentation of the neonatal outcome among women ≥40 years is of paramount importance. This study aimed to determine neonatal outcome of babies born to women ≥40 years at the University Hospital of the West Indies (UHWI). METHODS This was a matched retrospective cohort study looking at the outcome of all babies born to women ≥40 years and control babies born to women aged 20–30 years at the UHWI over a 2-year period. POPULATION All women aged ≥40 years who delivered a singleton live baby at the UHWI between 1 January 2012 and 31 December 2013 were included in this study. A control woman aged 20–30 years who delivered a singleton live baby nearest in time following the index case within a 24 h period was also included in the study. PROCEDURE Cases and controls were identified from the labour ward admission book. Maternal demographic data (age, gravidity, parity, mode of delivery, chronic illness) and neonatal demographic data (birth weight, gestational age if premature, Apgar score) were recorded. Babies admitted to the neonatal unit from the labour ward or the postnatal ward/home were identified from the neonatal unit admission book. Dockets of all babies admitted to the neonatal unit were reviewed and data on reason for admission, interventions, duration of stay and outcome of admission were recorded using a data extraction sheet. Outcome measures were preterm birth, low birth weight, low 5 min Apgar score <7, admission to the neonatal unit and neonatal death. Ninety-eight percent (100/102) of dockets were available for review. DEFINITIONS A preterm infant was defined as one delivered before 37 completed weeks of gestation. A low birth weight infant was defined as any neonate whose birthweight was <2500 g. A small for gestational infant was defined as any neonate whose birthweight was <10th percentile on the World Health Organization growth charts for term infants and the Fenton preterm growth charts for preterm infants. DATA ANALYSIS Descriptive analyses were performed. Analysis of differences between babies born to women ≥40 years and those born to women 20–30 years was performed using the student t test for continuous variables and the Chi-squared test for categorical variables. Statistical significance was taken at the level p < 0.05. Statistical analyses were performed using Statistical Package for the Social Sciences version 14 (SPSS Inc., Chicago, IL). ETHICAL APPROVAL Ethical approval for the conduct of this study was granted by the University of the West Indies Mona Research Ethics Committee. RESULTS Four hundred and six women fulfilled inclusion criteria for this study: 198 were women ≥40 years and 208 women were 20–30 years. The mean maternal age was 41.5 ± 1.7 years and 25.1 ± 2.6 years for the older women and their younger counterparts, respectively. There were 181 (91%) multigravid women ≥40 years compared with 109 (52%) mutigravid women in the younger group. Older women were more likely to have a chronic illness (hypertensive disorders in pregnancy and diabetes) than their younger counterparts (OR: 3.0; CI: 1.8–4.7). Women ≥40 years (108; 55%) were also more likely to be delivered via caesarean section than their younger counterparts (56; 27%) (OR: 3.1; CI: 2.1–4.8). Women ≥40 years accounted for 50 of 68 (74%) of the elective caesarean sections and 59 of 97 (61%) of the emergency sections performed, p < 0.001. The major reasons for emergency sections in the older women were foetal jeopardy (31%), failure to progress (23%), severe pre-eclampsia (13%) and a history of previous caesarean section in active labour (13%). Four hundred and six neonates were born to women in the study, M:F 1:1.2. There were 198 neonates delivered to women ≥40 years and 208 delivered to their younger counterparts. There was no significant difference in mean birth weight, gestational age and 1 and 5 min Apgar scores between neonates born to women ≥40 years and those born to their younger counterparts (Table 1). Similarly, there was no difference in these variables between neonates born to primigravid women ≥40 years and their younger primigravid counterparts, or multigravid women ≥40 years and their younger multigravida counterparts (p > 0.05). Among women ≥40 years, there was no difference in these variables between babies born to primigravida and multigravida women (p > 0.05). Table 1 Demographics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Table 1 Demographics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 Variable Women ≥40 years Women 20–30 years Independent sample t-test N = 198 N = 208 p-value Mean± SD Mean± SD Gestational age (weeks) 37.2 ± 2.2 37.5 ± 2.3 0.18 Birth weight (g) 2984 ± 679 3042 ± 607 0.37 Apgar 1 min 8.0 ± 1.7 7.8 ± 1.8 0.18 Apgar 5 min 8.9 ± 1.0 8.8 ± 1.0 0.11 A greater proportion of preterm, low birth weight and very low birth weight infants were born to women ≥40 years; however, this did not reach statistical significance (p > 0.05) (Table 2). There was also no difference in the number of preterm and low birth weight infants between primigravida older and younger women. However, multigravid women ≥40 years were more likely to deliver a Low birth weight (LBW) infant (32; 17%) than their multigravid younger counterparts (10; 9%) (OR: 2.1; CI: 1.0–4.5). No difference in the number of preterm or low birth weight infants was noted between primigravid and multigravid women ≥40 years. There was also no difference in a low 5 min Apgar score < 7 between babies of older and younger women (p > 0.05). Table 2 Clinical characteristics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Table 2 Clinical characteristics of babies born to women ≥40 years and those born to women 20–30 years at the UHWI 2012–13 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Variable Women ≥40 years Women 20–30 years Chi-squared test N = 198 N = 208 p-value Preterm 30 (15) 20 (10) 0.06 Low birth weight 35 (18) 24 (12) 0.05 Very low birth weight 9 (5) 5 (2) 0.18 Small for gestational age 21 (11) 18 (9) 0.31 Large for gestational age 5 (3) 7 (3) 0.42 Low 5 minAPGAR <7 5 (3) 6 (3) 0.53 Neonatal unit admission 45 (23) 47 (23) 0.53 Death 3 (2) 3 (1) 0.63 Ninety-two (23%) neonates were admitted to the neonatal unit, 45 (49%) from mothers ≥40 years and 47 (51%) from their younger counterparts (p = 0.5). Seventy-three percent of neonates born to women ≥40 years who required admission were admitted directly after birth compared with 57% of those born to younger women (p = 0.3). Twenty percent of neonates born to the older women were admitted from the post-natal ward compared with 30% for the younger women (p > 0.05). The main reasons for admission in both groups was presumed sepsis and neonatal jaundice. Seven percent of neonates born to women ≥40 years initially went home and then were subsequently admitted compared with 13% for their younger counterparts (p > 0.05). The main reasons for admission were presumed sepsis, neonatal jaundice and weight loss. There were no readmissions to the neonatal unit from either group. Neonates born to women 20–30 years who were admitted to the neonatal unit were more likely to have a sepsis screen performed, and those born to women ≥40 years were more likely to be treated for jaundice (Table 3). There were two babies with chromosomal abnormalities (trisomy 18 and 21) born to women ≥40 years during the study period. The median length of stay on the Neonatal Unit was 8 (interquartile range (IQR): 4–12.5) and 8 (IQR: 5.5–11) days for neonates born to women ≥40 years and their younger counterparts, respectively. Three neonates born to women ≥40 years died—two were extremely premature and one died from cardiac insufficiency. Similarly, three neonates born to women 20–30 years died, all of whom were extremely premature. Table 3 Morbidities of neonates admitted to the neonatal unit born to women ≥40 years and those born to women 20–30 years at the UHWI 2011–13 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Mechanical ventilation, synchronized intermittent mandatory ventilation via endotracheal tube; CPAP, continuous positive airway pressure; NNJ, neonatal jaundice. Table 3 Morbidities of neonates admitted to the neonatal unit born to women ≥40 years and those born to women 20–30 years at the UHWI 2011–13 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Course of admission Women ≥40 years Women 20–30 years Chi-squared test N = 45 N = 47 p value Mechanical ventilation 4 (9) 1 (2) 0.18 CPAP 7 (16) 6 (13) 0.48 Sepsis screen 28 (62) 40 (87) 0.006 Culture-positive sepsis 3 (7) 8 (17) 0.2 Anaemia 8 (17) 6 (18) 0.51 Transfusion 8 (17) 6 (18) 0.51 Hypoglycaemia 5 (11) 2 (4) 0.21 NNJ 28 (62) 18 (40) 0.03 Mechanical ventilation, synchronized intermittent mandatory ventilation via endotracheal tube; CPAP, continuous positive airway pressure; NNJ, neonatal jaundice. DISCUSSION This study found that there was no difference in the delivery of a preterm or low birth weight infant between women ≥40 years and their younger counterparts. There was also no difference in the number of babies with low 5 min Apgar scores or in the number of neonatal admissions or deaths. In this study, women ≥40 years were no more likely to deliver a LBW infant than their younger counterparts; these findings are similar to that of Bianco et al. [1] and Wang et al. [2]. They however, differ from findings of studies from the UK [3], South Africa [5], Iran [20] and Turkey [21], where older women were found to be more likely to deliver a low birth weight infant. Similar to a study of Cameroon, we found that multigravid women aged ≥40 were more likely to deliver a LBW infant than their multigravid younger counterparts [16]. This increased frequency of LBW in the multigravida older women >40 years may reflect the interventions of the obstetricians and the increased occurrence of chronic illness such as the hypertensive diseases of pregnancy, which may affect utero placental function. This association has also been postulated by Gilbert et al. [22] in the USA. Primigravid older women, however, were at no increased risk of delivering a LBW infant when compared with their younger controls. We also did not demonstrate any difference by gravidity in the delivery of a LBW infant among older women, which is in contrast to Delpisheh et al. and Shaikh et al. who both found an increased incidence of LBW infants in primigravida women ≥40 years compared with multigravid women ≥40 years [3, 18]. This study did not find an increased occurrence of a low 5 min Apgar score <7 in neonates of older women in contrast to studies by Ates et al., Ngowa et al. and Cakmak Celik et al. [11, 16, 19]. This finding may be influenced by the increased number of older women who received an emergency caesarean section and may reflect timely intervention when foetal compromise is detected. Equal proportions of babies were admitted to the neonatal unit for the older and younger women. Neonatal morbidities during the course of admission were similar for the two groups except that babies born to the older women had an increased occurrence of neonatal jaundice. Also, babies born to the younger women had an increased rate of being screened for sepsis; again this is to be expected, as a greater proportion of them were admitted from home and a common reason for admission from home is to rule out sepsis. There was no significant difference noted in the length of stay for hospital admission. There were two babies with chromosomal abnormalities both born to the older women; this is not unexpected as the risk for chromosomal abnormalities increases with age. Women ≥40 years need to receive routine counselling about the risk of having a baby with chromosomal abnormalities. There were the same number of neonatal deaths in both groups and they were related to extreme prematurity. LIMITATIONS This was a retrospective chart review, as such data collection was limited to data already recorded. Another limitation to this study would be if any of the neonates after discharge from hospital presented to another health care facility for admission. We, however, believe this to be highly unlikely, as the mothers and their infants at UHWI usually return to the post-natal ward with their babies anytime up to 6 weeks of life if there is a problem. Although a greater proportion of babies born to women ≥40 years were preterm and low birth weight, this did not reach statistical significance; this finding may possibly be as a reflection of an inadequate sample size. RECOMMENDATIONS Women ≥40 years should be counselled about the increased risk of having an operative delivery and a baby with chromosomal abnormalities; they, however, can be reassured that they are at no greater risk for a poor neonatal outcome than their younger counterparts. CONCLUSION Although women ≥40 years were found to be at increased risk of having an operative delivery, no increased risk of adverse neonatal outcome was noted. REFERENCES 1 Bianco A , Stone J , Lynch L , et al. Pregnancy outcome at age 40 and older . Obstet Gynecol 1996 ; 87 : 917 – 22 . Google Scholar CrossRef Search ADS PubMed 2 Wang Y , Tanbo T , Abyholm T , et al. The impact of advanced maternal age and parity on obstetrics and perinatal outcomes in singleton gestations . Arch Gynecol Obstet 2011 ; 284 : 31 – 7 . Google Scholar CrossRef Search ADS PubMed 3 Delpisheh A , Brabin L , Attia E , et al. Pregnancy late in life: a hospital-based study of birth outcomes . J Womens Health 2008 ; 17 : 965 – 70 . 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Google Scholar PubMed © The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Journal of Tropical PediatricsOxford University Press

Published: Jul 18, 2017

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