A woman 45 years of age or older is considered to be of very advanced maternal age. In Australia, 0.1% of parturients are in this category at present. The investigators undertook a retrospective cohort study of women aged 45 or above at the time of delivery, all of whom delivered at 20 or more weeks of gestation. In the 108,818 women reviewed, 76 women of very advanced maternal age had 77 pregnancies (incidence ϭ 0.7 per 1000 births). The mean age was 46 years. Sixteen women in the study were primiparous. In multiparas, a mean of 8.8 years had passed since the last live birth. More than half the women had had at least one miscarriage and 13 (17% of the total) reported having 3 or more. Only 14% of women required assisted reproduction. The most frequent medical problems were depression, present in 9 women, and uterine leiomyomas in 4. No chromosomal abnormalities were found in the 53% of pregnancies that were evaluated.Two thirds of pregnancies were free of complications. Ten women had pregnancy-related hypertensive disorders compared with 10% of women 20 to 29 years of age. Two women were delivered before term because of preeclampsia. Gestational diabetes was diagnosed in 8% of pregnancies; only one woman received insulin. Labor began spontaneously in 36% of pregnancies and was induced in 17%, most often "electively" or because of postdate status or spontaneous rupture of membranes at term. The rate of cesarean section was 49% compared with 23% in the younger women. Four women required manual removal of the placenta because of bleeding, and 3 had postsection wound infections.Eight of 78 live-born infants were small-for-gestational age, whereas 6 were large-for-gestational age. Seven singleton births and both sets of twins were born prematurely for a variety of reasons, the most common being premature rupture of membranes. Thirteen infants, 17% of the total, were admitted to the special care nursery; prematurity and respiratory distress syndrome accounted for 6 and 4 admissions, respectively. The overall rate of special care was 16.5%. Five infants in the study group (6%) had congenital abnormalities.The findings in this large-scale study of women aged 45 or above are, in general, reassuring for older women who are in good health and who have a chromosomally normal fetus.
Background: Maternal mortality is a rare occurrence in developed nations. Given the low maternal mortality rate, other markers must be used to assess maternal risk and quality of obstetric care. One such is admission to critical care. Aims: To determine the rate of admission, diagnosis and management of women from conception and up to 6 weeks postpartum to critical care units including coronary care (CCU), high dependency unit (HDU) and intensive care units (ICU). Methods: We performed a retrospective review of obstetric patients requiring critical care admission from January 1995 to August 2010. Demographic details, obstetric history, place of admission (CCU, HDU or ICU) and fetal/neonatal outcomes were examined as were initial indication for critical care admission, final diagnosis and treatment administered. Results: Data were available from 308 admission incidents. There were 259 (84%) admissions to ICU and 49 (15.9%) to CCU. More than a third of women were transferred from another institution. Those women transferred were more unwell and had a higher mortality rate than local women. Primary diagnoses: obstetric haemorrhage (ICU 30.9%), hypertensive disorders of pregnancy (ICU 16.2%, CCU 12.2%), infection (ICU 14.2%, CCU 6.1%), pre-existing cardiac disease (ICU 9.3%, CCU 55.1%). Conclusions: The obstetric population represents only a small percentage of critical care utilisation and overall morbidity and mortality. However, this population is an important and growing group. Increased surveillance peripartum in a critical care facility allows earlier detection of maternal compromise and detailed management. Analysis of these ‘near misses’ in obstetrics aims to improve pregnancy outcomes.
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