Original Article

Access this article online

Quick Response Code:
The association of advanced maternal
age with maternal and neonatal
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

outcomes of pregnancy in Filipino

patients in a tertiary medical center:
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

An analytical cross‑sectional study

Website:
www.pogsjournal.org

DOI:
10.4103/pjog.pjog_36_21 Leolina Remeceta M Gamboa‑Chua1, Agnes L. Soriano-Estrella1,2

Abstract:
BACKGROUND: For the past decade, advanced maternal age (AMA) became more common in
developed and developing countries due to the postponement of pregnancy because of career
goals, widespread use of family planning, and advances in assisted reproductive techniques. This
increase bears an impact on maternal and perinatal outcomes. The link between AMA and adverse
maternal, perinatal, and neonatal outcome showed contradicting results. This study was conducted
to investigate the association between AMA and adverse outcomes among nulliparous, Filipino with
singleton pregnancies who gave birth in a private tertiary hospital.
METHODOLOGY: Medical records of patients admitted for delivery between January 2015 and
December 2019 were reviewed retrospectively. The control (20–34 years), AMA 35–39 years, very
AMA 40–44 years, and extremely advanced maternal age (EAMA) 45 years and above groups
included 206, 111, 18, and 2, respectively.
RESULTS: Five‑year total deliveries at a private tertiary hospital were 8495 with a prevalence of
38.9% (95% confidence interval CI: 33.6%–44.3%) for elderly Filipino primigravids. AMA is a risk factor
for diabetes mellitus and small for gestational age newborn in all 3 advanced age groups. Pregnancy
induced hypertension, having cesarean section, admission of newborn to neonatal intensive care unit,
and administration of antibiotics were more common to AMA but same risk for EAMA. AMA predisposes
to having oligohydramnios, placenta previa and preterm delivery but pregnancy at EAMA predisposes
more complications in maternal and neonatal outcomes such as having polyhydramnios, abruptio
placenta, postpartum hemorrhage, maternal and neonatal death, low Appearance Pulse Grimace
1
Department of Obstetrics
Activity and Respiration score, and stillbirth. There is no noted association between AMA and large
and Gynecology,
for gestational age newborn, having meconium staining and delivering by classical cesarean section.
St. Luke’s Medical Center-
Global City, Taguig City, CONCLUSION: AMA in Filipino gravida patients is markedly linked with adverse obstetrical, perinatal,
Philippines, 2Department and neonatal outcomes. This study confirms the current trend among women over 45 years that
of Obstetrics and leads to more significant obstetric complications and neonatal morbidities.
Gynecology, Philippine Keywords:
General Hospital, Advanced maternal age, pregnancy outcomes.
University of the
Philippines-Manila

Address for Introduction

correspondence: This is an open access journal, and articles are

T
Leolina Remeceta distributed under the terms of the Creative Commons he fertility rate of women follows a
Medenilla Gamboa-Chua, Attribution‑NonCommercial‑ShareAlike 4.0 License, which characteristic pattern; after menarche,
MD, allows others to remix, tweak, and build upon the work
Obstetrics and non‑commercially, as long as appropriate credit is given and the rate starts at low level then peaks at ages
Gynecology, St. Luke’s new creations are licensed under the identical terms.
Medical Center-Global
City, Taguig, Philippines. How to cite this article: Gamboa-Chua LR,
E‑mail: yim_jel@yahoo. Forreprintscontact:WKHLRPMedknow_reprints@wolterskluwer.com
Soriano-Estrella AL. The association of advanced
com maternal age with maternal and neonatal outcomes
*Third Place, 2021 PHILIPPINE OBSTETRICAL AND
of pregnancy in Filipino patients in a tertiary medical
Submitted: 14-Oct-2021 GYNECOLOGICAL SOCIETY (Foundation), INC. (POGS)
center: An analytical cross-sectional study. Philipp
Accepted: 14-Oct-2021 Residents’ Research Paper Contest, July 05, 2021, Online J Obstet Gynecol 2021;45:196-203.
Published: 13-Dec-2021 Platform: ZOOM Webinar

196 © 2021 Philippine Journal of Obstetrics and Gynecology | Published by Wolters Kluwer Health – Medknow
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

20–29 years, and will gradually decline until complete assisted with vacuum/forceps device[6]
cessation after menopause. Both ends of the reproductive b. Cesarean delivery – Delivery laparotomy and then
spectrum shows a higher risk of adverse pregnancy hysterotomy[6]
outcome.[1] It has been shown that at age ≥35 years, 5. Hypertension in pregnancy
women are more likely to experience gestational diabetes a. GH – blood pressure (BP) of ≥140 mmHg systolic
mellitus (GDM), placenta previa, malpresentation, or ≥90 mmHg diastolic, or both, on two separate
and operative vaginal delivery than younger women occasions at least 4hours apart after 20 weeks of
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

aged 20–29 years. Other observed complications that gestation in a woman with previously known
are prevalent to advanced maternal age (AMA) are normal BP. It occurs in women with hypertension
preeclampsia, gestational hypertension (GH), cesarean without proteinuria or no severe features develop
delivery (CS), abruptio placenta, preterm delivery, low and BP level returns to normal in postpartum
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

birth weight, and stillbirth.[2] Furthermore, the prevalence period[8]

of chronic medical conditions (e.g., diabetes mellitus, b. Preeclampsia – first time‑onset hypertension
hypertension) and other diseases with a possible influence with new onset proteinuria, or symptoms such
on a course of pregnancy such as cancer, are higher among as headache, right upper quadrant pain, blurring
older patients. Multiple studies suggests that the incidence of vision, with or without proteinuria, occurring
rate of perinatal complications only begins to increase after after 20 weeks age of gestation and frequently
the age of 35 years, but the most significant growth can near term. GH with the absence of proteinuria but
be observed after the age of 40 years.[3] with associated thrombocytopenia, impaired liver
function and severe persistent right upper quadrant
Worldwide statistics show significant increase in average or epigastric pain, renal insufficiencies, pulmonary
age of first birth with the greatest increase seen among edema or new onset headache not responsive to
the age 35–39 years. Although the birth rate of these acetaminophen is also classified as preeclampsia[8]
women continues to grow, overall number remains 6. GDM – condition consists of carbohydrate or glucose
small.[4] In the Philippines, median age at first birth for intolerance with first recognition during pregnancy[9]
all women age 25–49 years is 23.5.[5] The trend of AMA 7. Placenta previa – presence of placental tissues
is contributed to changing sociodemographics, these which extends over the internal cervical os during
women of AMA are more likely to be well educated, pregnancy[10]
higher socioeconomic status, and low parity compared 8. Abruptio placenta – early placental separation from
to older mothers from the past.[4] Furthermore, recent the uterine lining prior delivery[11]
changes in work and society have been reflected in 9. Gestational age – time elapsed between the first day
women’s desire to develop their careers, obtain financial of the last normal menstrual period (LMP) and the
security and build stable relationship with their partner day of delivery. If a patient is unsure, the gestational
before becoming mothers. Higher education of these age is based on the earliest sonographic aging until
women leads to a better knowledge and awareness of 13 6/7 weeks[12] age of gestation will be based on the
different types of contraception and greater access to 1st day of LMP or first trimester ultrasound while
birth control methods.[3] In addition, the most significant pediatric aging will be based on the Ballard score[13]
reason for delayed child bearing is the progress in 10. Preterm labor and birth – birth <37 completed weeks
assisted reproductive technology (ART) (e.g., in vitro or <259 days since the 1st day of the LMP[14]
fertilization [IVF], oocyte donation, intrauterine 11. Preterm prelabor rupture of membranes (PPROM) –
insemination [IUI]) which contributed to the rise of rupture of fetal membranes prior labor and <37 weeks’
number of pregnancies in women in their 40–50s.[2,4] gestational age[15]
12. Stillbirth – Fetal death; delivery of dead fetus
This study is started with the intent that appropriate at ≥20 weeks, or weight ≥500 g and exhibiting no
interventions may be given to further improve signs of life such as breathing, heartbeats, umbilical
pregnancy outcomes among women from the older end cord pulsations or definite voluntary muscle
of the reproductive age spectrum. movements[16]
13. Early neonatal death – death of a liveborn infant
Definition of terms regardless of gestational age at birth, within the first
1. AMA – Childbearing ≥35 years of age[6] 28 completed days of life[17]
2. Very AMA (VAMA) – Childbearing ≥40 years of 14. A p p e a r a n c e P u l s e G r i m a c e A c t i v i t y a n d
age[7] Respiration (APGAR) score – scoring for rapid
3. Extremely AMA (EAMA) – Childbearing ≥45 years assessment of a newborn’s clinical status at 1 and
of age[7] 5 min after birth, including need and response from
4. Operative delivery resuscitation; consists of 5components, namely, heart
a. Operative vaginal delivery ‑ Delivery vaginally rate, respiratory effort, muscle tone, reflex irritability,
Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021 197
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

and color. Each component is assigned a score of 0, Table 1: Data collection form
1, or 2. Poor APGAR score is a score of <7 at 5 min DEMOGRAPHIC DATA
period[18] Age Nationality
15. Small for gestational age (SGA) – birthweight CLINICAL DATA
<10th percentile for gestational age[18] BMI Gravidity/ Parity
16. Large for gestational age – birthweight >90th percentile ADMITTING DIAGNOSIS
for gestational age[18] Pregnancy Infertility
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

17. Intrauterine growth restriction (IUGR) – sonographic Spontaneous Yes

fetal weight <10th percentile of expected weight for Assisted (IVF/IUI) No
Medical Condition Internal examination
gestational age (Hadlock formula), linked with the
Chronic HPN upon
increased pulsatility index of umbilical artery ≥2
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

GHPN/ Preeclampsia admission Cervical

standard deviations, and a postpartum verification dilatation
Gestational DM
with a birthweight <10th percentile.[19] cm
Thyroid disease
Membranes
Bronchial Asthma
Objectives Heart disease
Intact
This study was initiated to determine the association Others
Ruptured
between AMA and adverse maternal and perinatal Presentation
outcomes among nulliparous, Filipino patients with Cephalic
singleton pregnancy compared to women aged Breech
20–34 years. The percentage of women who were Transverse
Amniotic fluid Placental location Perinatal complication
at AMA at the time of delivery and its adverse
Normal Normal PROM
maternal outcome (i.e. maternal death, operative
Oligohydramnios Previa Others
delivery); pregnancy‑related complications (i.e. prelabor
Hydramnios Accreta
rupture of membranes, abnormal placentation,
Mode of delivery If abdominal If CS, indication
postpartum hemorrhage); and adverse neonatal NSD LTCS Dystocia
outcomes (i.e. stillbirth, early neonatal death, preterm Degree of tear Classical Malpresentation
birth, poor APGAR score, large or SGA, and neonatal OFE NRFHR
intensive care or intermediate medical care unit Degree of tear Placenta previa
admission (NICU/IMCU) were obtained. Vacuum Deteriorating maternal
Degree of tear status
Methodology Abdominal Others
Birth weight Livebirth Meconium staining
This study was a retrospective cross‑sectional study grams Yes Yes
of Filipino women of at least 20 years who delivered (_)SGA (_)AGA (_)LGA No No
singleton from January 2015 to December 2019 at Pediatric aging 5minute APGAR Disposition
the Department of Obstetrics and Gynecology of the Weeks score Room in
St. Luke’s Medical Center‑Global City. The study (_) Preterm 0-3 Low IMCU
was approved by the Research Ethics Committee of (_) Term 4-6 intermediate NICU
the said institution. Patients who met the following (_) Post term 7-10 Normal Antibiotics: (_)Y (_)N
criteria were enrolled: (1) nulliparous, (2) singleton, (3) Surfactant: (_)Y (_)N
gestational age ≥20 weeks, and (4) birthweight ≥500 g.
The exclusion criteria were: (1) multiple gestation, (2)
any concomitant chronic diseases diagnosed prior 1. Maternal demographic data: age, body mass
to pregnancy, (3) history of uterine surgery, (4) any index (BMI), spontaneous or assisted pregnancy (IVF
Mullerian abnormality, (5) presence of uterine or or IUI), gestational age upon delivery, presence of
adnexal mass, and (6) smoking, alcohol or illicit drug use medical conditions, abnormal placentation, and
since the said conditions were associated with increased PPROM
risk for poor pregnancy outcomes regardless of age. 2. Pregnancy outcome: route of delivery, indication
for operative delivery, maternal morbidity or
The medical records of eligible patients were retrieved mortality
and assessed and all identifying information were 3. Neonatal outcomes: occurrence of stillbirth or
removed. The patients’ name was coded during input. neonatal death, pediatric aging, APGAR score,
Only the data pertinent to the objectives of the study birthweight, and NICU/IMCU admission.
were extracted from the medical records and recorded on
the patient data extraction from [Table 1]. Data included Charts collected and data collection forms retrieved were
were the following: only handled by the authorized investigators.
198 Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

Statistical analysis Clinical characteristics of four maternal groups and

Demographic data, maternal and clinical outcomes of pregnancy complications are shown in Table 3. For
patients were gathered and encoded into Microsoft the control and AMA, majority has BMI of overweight
Excel Spreadsheet. Descriptive statistics such as mean, while VAMA and EAMA were mostly Obese I. All
median, standard deviation were used to summarize groups had spontaneous pregnancy and no infertility.
the characteristics of the participants. Frequency Based on the performed Chi‑square test, there is a
significant association between AMA and assisted
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

and proportion were used for categorical variables

while mean and standard deviation for numerical pregnancy (χ2 = 36.5, P < 0.001) and maternal age and
infertility (χ2 = 115.7, P < 0.0001).
variables. Fisher’s Exact or Chi‑square test was
used to determine the difference frequency profile The likelihood of patients being admitted for labor
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

between groups. Group means were compared using induction [Table 4] is 2.5 times for AMA (z = 3.57,
t‑test or Mann–Whitney U‑test. Odds and risk ratios P = 0.0002) and 6.60 times for VAMA (z = 2.90, P = 0.0019).
were reported to measure the degree of association. For patients being admitted, no association whether they
All statistical analysis was performed at 5% level of came in active labor (internal examination of ≥4 cm)
significance. or ruptured bag of water in all three groups. There
is likelihood that patients having malpresentation is
Results 4.2 times in VAMA and 13.28 times in EAMA compared
to younger age group.
Five‑year total deliveries were 8495 with the prevalence
of 38.9% (95% confidence interval [CI]: 33.6%–44.3%) The likelihood of patients having pregnancy‑induced
of AMA obtained and demographic analysis hypertension (PIH) [Table 5] is 2.7 times for AMA (z = 2.46,
showed that the mean age of the study group was P = 0.0070) and 6.9 times for VAMA (z = 3.281, P = 0.0005).
38 ± 2.01 years (range 35–47). The likelihood of patients having GDM is 3.1 times for
AMA (z = 3.68, P = 0.0001) and 4 times for VAMA (z = 2.64,
A total of 337 samples were collected through P = 0.0042). The calculated odds ratio for EAMA compared
randomization comprising of 206 (61%) for control, to younger age group is 1.562, however, there is no
111 (33%) for AMA of 35–35 years age, 18 (5%) for VAMA sufficient evidence to say that this association is statistically
of 40–44 years age and 2 (1%) for EAMA of >45 years of significant (z = 0.285, P = 0.3879). There is association
age [Table 2]. with oligohydramnios in AMA (z = 2.41, P = 0.081) about
2.8 times more likely to be observed in younger age
Table 2: Sample data collected and frequency group but no significant association in VAMA (z = 0.521,
Age group (years) Frequency (%) P = 0.3013) and EAMA (z = 0.835, P = 0.2019). For
20‑34 206 (61.1) polyhydramnios, there is no link with maternal age for
35‑39 111 (32.9) both AMA and VAMA groups but 82.6 times likelihood
40‑44 18 (5.3) to EAMA (z = 2.102, P = 0.0177). For the occurrence of
≥45 2 (0.6) abnormal placentation, placenta previa is 3.6 times more
Total 337 likely to occur in AMA (z = 1.89, P = 0.0291). But for

Table 3: Descriptive data of Filipino advanced maternal age with singleton births
Characteristics Age group (years) P (χ2)
20‑34 (%) 35‑39 (%) 40‑44 (%) ≥45 (%)
BMI (kg/m2)
Underweight <18.5 3 (1.5) 1 (0.9) 0 0 <0.0001 (51.1)
Normal 18.5‑24.9 80 (38.8) 16 (14.4) 0 0
Overweight 25.0‑29.9 92 (44.7) 50 (45.0) 6 (33.3) 1 (50.0)
Obese Class I 30.0‑34.9 28 (13.6) 40 (36.0) 11 (61.1) 1 (50.0)
Obese Class II 35.0‑39.9 3 (1.5) 4 (3.6) 1 (5.6) 0
Obese Class III≥40.0 0 0 0 0
Pregnancy
Spontaneous 203 (98.5) 93 (83.8) 13 (72.2) 1 (50.0) <0.001 (36.5)
Assisted (IVF/IUI) 3 (1.5) 18 (16.2) 5 (27.8) 1 (50.0)
N/A
Infertility 6 (2.9) 47 (42.3) 14 (77.8) 2 (100.0) <0.0001 (115.7)
Not infertility 200 (97.1) 64 (57.7) 4 (22.2) 0 (0.0)
IVF: In vitro fertilization, IUI: Intrauterine insemination, BMI: Body mass index

Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021 199
 nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

200
Table 4: Comparison of all the women aged 35‑39 and ≥40 with the control group (20‑34) on maternal characteristics upon admission
Age group (years)
Characteristics AMA 35‑39 years old VAMA 40‑44 years old EAMA ≥45 years old
Z score (P χ2) OR (95% CI) Z score (P χ2) OR (95% CI) Z score (P χ2) OR (95% CI)
Not in labor 3.573 (0.0002) 2.446 (1.498‑3.996) 2.724 (0.0032) 6.600 (1.698‑25.659) 1.035 (0.1504) 5.000 (0.237‑105.431)
Internal examination of ≥4 cm −4.621 (1.0000) 0.277 (0.161‑0.478) −2.670 (0.9962) 0.100 (0.018‑0.542) −0.935 (0.8251) 0.234 (0.011‑4.924)
Ruptured amniotic fluid membrane 1.636 (0.0509) 1.729 (0.897‑3.331) 0.304 (0.3806) 1.242 (0.306‑5.040) 0.316 (0.3760) 1.640 (0.076‑35.251)
Nonvertex fetal presentation 0.749 (0.2268) 1.373 (0.599‑3.149) 2.342 (0.0096) 4.120 (1.260‑13.472) 2.180 (0.0146) 13.276 (1.298‑135.809)
AMA: Advanced maternal age, VAMA: Very advanced maternal age, EAMA: Extremely maternal age, OR: Odds ratio, CI: Confidence interval

Table 5: Comparison of all the women aged 35‑39 and ≥40 with the control group (20‑34) on pregnancy complications and mode of delivery
Age group (years)
Characteristics AMA 35‑39 VAMA 40‑44 EAMA ≥45
Z score (P χ2) OR (95% CI) Z score (P χ2) OR (95% CI) Z score (P χ2) OR (95% CI)
Pregnancy complications
Pregnancy induced hypertension 2.458 (0.0070) 2.731 (1.226‑6.082) 3.281 (0.0005) 6.926 (2.180‑22.009) 0.775 (0.2191) 3.400 (0.154‑75.030)
Gestational diabetes mellitus 3.679 (0.0001) 3.056 (1.685‑5.540) 2.639 (0.0042) 4.060 (1.434‑11.494) 0.285 (0.3879) 1.562 (0.073‑33.529)
Oligohydramnios 2.416 (0.0079) 2.783 (1.213‑6.386) 0.521 (0.3013) 1.604 (0.271‑9.506) 0.835 (0.2019) 3.743 (0.169‑83.020)
Polyhdramnios 0.308 (0.3792) 1.852 (0.036‑93.976) 1.197 (0.1156) 11.162 (0.215‑578.989) 2.103 (0.0177) 82.600 (1.350‑5052.317)
Placenta previa 1.894 (0.0291) 3.582 (0.956‑13.418) 1.595 (0.0554) 4.984 (0.692‑35.883) 1.496 (0.0674) 11.629 (0.467‑289.594)
Abruptio placenta 0.308 (0.3792) 1.852 (0.036‑93.976) 1.197 (0.1156) 11.162 (0.215‑578.989) 2.103 (0.0177) 82.600 (1.350‑5052.317)
Prelabor rupture of membrane −0.388 (0.6511) 0.858 (0.395‑1.861) 0.153 (0.4392) 1.145 (0.202‑6.488) ‑0.454 (0.6751) 0.491 (0.023‑10.611)
Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

Postpartum hemorrhage 0.308 (0.3792) 1.852 (0.036‑93.976) 1.197 (0.1156) 11.162 (0.215‑578.989) 2.103 (0.0177) 82.600 (1.350‑5052.317)
Death 0.308 (0.3792) 1.852 (0.036‑93.976) 1.197 (0.1156) 11.162 (0.215‑578.989) 2.103 (0.0177) 82.600 (1.350‑5052.317)
Mode of delivery
Cesarean section 7.010 (0.0001) 9.579 (5.092‑18.018) 2.894 (0.0019) 5.814 (1.765‑19.151) 1.210 (0.1132) 6.564 (0.311‑138.446)
Classical CS 0.407 (0.3421) 1.528 (0.198‑11.811) 0.389 (0.3488) 1.903 (0.074‑48.881) 1.407 (0.0797) 11.800 (0.379‑367.510)
Assisted vaginal 0.604 (0.2728) 1.768 (0.279‑11.223) 2.911 (0.0018) 24.556 (2.846‑211.895) 1.322 (0.0931) 14.733 (0.273‑795.738)
AMA: Advanced maternal age, VAMA: Very advanced maternal age, EAMA: Extremely maternal age, OR: Odds ratio, CI: Confidence interval, CS: Cesarean delivery

Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

abruptio placenta and post‑partum hemorrhage, there was

81.000 (1.324‑4954.672)

82.600 (1.350‑5052.317)

82.600 (1.350‑5052.317)
82.600 (1.350‑5052.317)
82.600 (1.350‑5052.317)
25.667 (0.827‑796.663)
no association with both AMA and VAMA but is 82.6 times

9.000 (0.375‑215.744)

6.169 (0.268‑141.863)
2.852 (0.130‑62.435)

1.640 (0.076‑35.251)
2.038 (0.094‑44.064)
likelihood in EAMA group (z = 2.102, P = 0.0177).

OR (95% CI)

AMA: Advanced maternal age, VAMA: Very advanced maternal age, EAMA: Extremely maternal age, OR: Odds ratio, CI: Confidence interval, SGA: Small for gestational age, LGA: Large for gestational age,
Patients in AMA (z = 7.010, P = 0.0001) and VAMA
EAMA ≥45 years old

(z = 2.894, P = 0.0019) are more likely to deliver by CS.

For those who underwent abdominal delivery, there is
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

no risk for delivering through classical CS for all groups

while for those who underwent vaginal delivery, an
increased likelihood of 24.6 times of having operative
vaginal delivery for VAMA (z = 2.911, P = 0.0018).
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

1.356 (0.0876)
2.094 (0.0181)
1.852 (0.0320)
0.666 (0.2528)
2.103 (0.0177)
1.137 (0.1277)
0.316 (0.3760)
0.454 (0.3249)
2.103 (0.0177)
2.103 (0.0177)
2.103 (0.0177)
Z score (P χ2)

For the maternal age in association to neonatal

Table 6: Comparison of all the women aged 35‑39 and ≥40 with the control group (20‑34) on neonatal complications

outcomes [Table 6], there was 4.2 times likelihood of

having preterm delivery with AMA (z = 2.44, P = 0.0073).
There was also no significant association between
postterm delivery and AMA and VAMA but 81 × likely
to occur in EAMA group (z = 2.094, P = 0.0181). The
11.571 (0.223‑601.148)
11.000 (1.086‑111.432)

11.162 (0.215‑578.989)

35.400 (1.390‑901.774)
11.162 (0.215‑578.989)
11.162 (0.215‑578.989)
12.573 (4.540‑34.824)
3.857 (0.570‑26.083)

2.644 (0.419‑16.671)

5.298 (1.833‑15.313)
0.407 (0.023‑7.148)

likelihood of patients giving birth to SGA is 5.8 times for

OR (95% CI)

AMA (z = 1.85, P = 0.0322), 11 times for VAMA (z = 2.03,

P = 0.0212) and 25.7 times for EAMA (z = 0.1.85,
VAMA 40‑44 years old

P = 0.0320). However, there is no noted association for

birthing large for gestational age to all three groups.
APGAR: Appearance pulse grimace activity and respiration, NICU: Neonatal intensive care, IMCU: Intermediate medical care unit

Delivering a newborn with low APGAR is 82.6 times

associated with EAMA (z = 2.10, P = 0.0177) but found
of no risk for AMA and VAMA. There was no noted
Age group (years)

−0.614 (0.7305)

4.871 (<0.0001)

association of delivering newborn with meconium

1.384 (0.0831)
1.215 (0.1122)
2.030 (0.0212)

1.197 (0.1156)
1.035 (0.1504)

3.079 (0.0010)
2.159 (0.0154)
1.197 (0.1156)
1.197 (0.1156)
Z score (P χ2)

staining for all three groups.

The likelihood of NICU/IMCU admission is 3.65 times

in AMA (z = 4.28, P < 0.001) and 12.57 times in
VAMA (z = 4.87, P < 0.001) but none in EAMA (z = 0.32,
P = 0.3760). At NICU/IMCU, the likelihood of
1.976 (0.039‑100.290)

5.606 (0.226‑138.780)
4.171 (1.325‑13.126)

5.804 (0.900‑37.421)

1.852 (0.036‑93.976)

1.852 (0.036‑93.976)
1.852 (0.036‑93.976)

administering antibiotics is 2.7 times in AMA (z = 2.96,

1.218 (0.499‑2.971)

1.900 (0.625‑5.781)
3.650 (2.016‑6.610)
2.706 (1.399‑5.232)

P = 0.0015) and 5.3 times in VAMA (z = 3.08, P = 0.0010).

OR (95% CI)

The use of surfactant in newborn admitted at NICU is

35 times more likely in VAMA (z = 2.16, P = 0.0154)
AMA 35‑39 years old

and EAMA (z = 2.10, P = 0.0177). The risk of having

stillbirth and neonatal death is 82.6 times more likely in
EAMA (z = 2.102, P = 0.0177), but the same risk for AMA
and VAMA compared to younger groups.
4.275 (<0.0001)
2.441 (0.0073)
0.340 (0.3670)
1.849 (0.0322)
0.434 (0.3322)
0.308 (0.3792)
1.131 (0.1290)

2.958 (0.0015)
1.053 (0.1462)
0.308 (0.3792)
0.308 (0.3792)
Z score (P χ2)

Discussion
AMA represents a substantial proportion of pregnancies
in higher‑income countries but only a few data on
pregnancy outcome in lower‑income countries. [20]
The note of shift of childbearing age to 5th decade and
beyond from third to fourth decade marks introduction
With meconium staining
NICU/IMCU admission

of two new terminologies; namely, VAMA and EAMA,

Low APGAR score
Birth weight: SGA

which is defined as childbearing at ≥40 and ≥45 years,

Perinatal outcome

With antibiotics
With surfactant
Characteristics

respectively.[7]
Postterm
Preterm

Stillbirth

PIH on this study is greatly associated with AMA

Death
LGA

and VAMA but not for EAMA. This could be due to

contrasting course of aging on hemodynamic changes
Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021 201
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

in pregnancy making adaptation to pregnancy more to labor assuming that it would be the patient’s last
difficult due to loss of myocardial compliance, decline delivery.[7] This generalization results in increased rate
in vascular responsiveness to endothelium‑dependent of CS delivery for nonmedical reasons, consequently
vasodilators, gradual loss of compliance, and less aortic making AMA as a risk factor for operative abdominal
flow during diastole.[6,21] Confounding variables also birth and also hypothesizing a biological basis for the
include preexisting medical condition, use of ART, findings of (1) a poor progression and longer duration
history of adverse pregnancy outcome, education, of labor with advancing age, (2) dystocia, and (3)
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

marital status, smoking, and BMI.[22] impairment of myometrial contractility due to reduced
sensitivity of myometrial oxytocin receptors as the most
AMA is more likely to develop some form of diabetes.[21] frequent reasons.[12,25]
This study showed significant association of all three
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

groups to GDM, which could be attributed to the changes A relevant increase in AMA and perinatal outcome
in metabolism of carbohydrates secondary to the fall of is attributed to the increasing number of women
pancreatic B‑cell function and sensitivity associated with postponing their age in having children. Reports show
advancing age. Hence, studies shows that up to 16% that AMA has a significantly increased risk of preterm
of AMA in pregnancy have an abnormal oral glucose birth, perinatal death, early neonatal mortality, low
tolerance test.[6,21] GDM and its complications, which birth weight, APGAR score of <7 at 5 min, and chance of
include macrosomia, polyhydramnios, and preterm NICU/IMCU admission.[20] Based from the data gathered,
labor, may also contribute to the increased prevalence all three groups of AMA were noted to be significantly
of pre‑eclampsia, placental abruption, and IUGR related associated with SGA, only AMA has been shown to
with AMA.[21] have linkage to preterm delivery but high likelihood of
AMA and VAMA to have newborn admitted at NICU/
Placenta previa has an incidence of 0.3%–2%. In IMCU and administration with antibiotics and as high
study conducted, placenta previa is 3.6 times more as 82.6 times likelihood of VAMA having low APGAR
likely associated in AMA but none in VAMA and score at 5 min, surfactant administration to newborn
EAMA. Placental abruption results form a cascade and perinatal death. These results were consistent with
of pathophysiological processes that complicates study conducted by Odibo et al.,[24] wherein preexisting
approximately 1% of births.[18] Placenta abruption is maternal diseases, reproductive‑assisted conceptions,
noted to be 82.6 times risk in EAMA. The impact of obesity, multifetal pregnancy, and parity variables
AMA on the risk of placental abnormalities may likely were controlled, disclosed that nulliparous women
due to decreased uterine blood flow, uteroplacental of advanced age with no known previous chronic
hypoperfusion, and major placental infarctions leading diseases, there is an increased odds of adverse neonatal
to hemorrhagic disorders in older women.[11,18] and perinatal outcome, including GH or preeclampsia,
GDM, CS and spontaneous late preterm delivery, but
Preterm birth is one of the most important factors in not spontaneous delivery before 34 weeks. Prolonged
determining neonatal morbidity and mortality.[23] In the rupture of membranes, PPROM, abruptio placenta,
study, it is noted to be linked to AMA but not with VAMA placenta previa, large for gestational age and operative
and EAMA. Proposed theories state that increased risk of vaginal delivery were also observed.[24]
preterm birth among AMA is contributed to early labor
induction for indicated medical conditions. Other factors The rate of fetal death is lowest at age of <30 but it
include hypertensive disorders, multiple gestations, and increases as age advances, with women age >40 having
infections like urinary tract infection.[21] a fetal death rate of twice of women younger than
30.[12] Based on the gathered data on this study, EAMA
The relationship between AMA and SGA is believed predisposed 82.6 times likelihood of having stillbirth
to be U‑shaped; it can be observed in women <30 and neonatal death compared to younger group. Even
and >40 years of age. It is noted that AMA is proven as after controlling common diseases associated with
an independent risk factor for IUGR.[24] This is consistent AMA and complications of pregnancy, AMA remains
with our findings that SGA is associated with all study as independent risk factor.[12]
group. While accurate association between AMA and
SGA has not been clearly established, studies suggested This study is limited by its monocentric character and
that the poor exchange of oxygen demonstrated in AMA retrospective study design aspect. In comparison with 1
may be the underlying factor.[24] local study in AMA done by Acda, et al.,[26] from a tertiary
referral center with 6.91% prevalence of AMA (95% CI:
AMA is frequently labeled as a higher risk even if there 6.11%–7.81%), it was suggested that there were no noted
are no known risk factors. High CS rate may be due difference in terms of maternal and neonatal outcomes
to the patient and attending doctor’s preferences not between elderly primigravida, however, the studied
202 Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021
 Gamboa‑Chua and Soriano‑Estrella: Advanced maternal age outcomes in Filipino pregnancy

hospital is a tertiary private facility that has a center Avnon T, et al. Perinatal outcomes of pregnancy in the fifth decade
for ART, thus obtained samples may have included and beyond – A comparison of very advanced maternal age
groups. Sci Rep 2020;10:1809.
more patients using these techniques and may have
8. ACOG practice bulletin No. 202: Gestational hypertension and
included in the higher middle to high socioeconomical preeclampsia. Obstet Gynecol 2019;133:e1‑25.
status wherein patients included were also on the 9. ACOG practice bulletin No. 190: Gestational diabetes mellitus.
higher age bracket with the prevalence of 38.9% (95% Obstet Gynecol 2018;131:e49‑64.
CI: 33.6%–44.3%). 10. Balayla J, Desilets J, Shrem G. Placenta previa and the risk of
Downloaded from http://journals.lww.com/pjog by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

intrauterine growth restriction (IUGR): A systematic review and

meta‑analysis. J Perinat Med 2019;47:577‑84.
Conclusion
11. Ahmed I. Impact of maternal age and parity in incidence of
placenta previa. Int J Curr Res 2017;9:53060‑4.
Advanced age in Filipino gravida patients are markedly
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023

12. Corda L, Khanapure A, Karoshi M. “Biopanic, advanced maternal

linked with adverse outcomes. During the study period, age and fertility outcomes.” In: Karoshi M, editor. A Textbook
there were 38.9% (95% CI: 33.6%–44.3%) AMA who of Preconceptional Medicine and Management 1‑16. Wetheral:
delivered. This study confirms the current trend among Sapiens; 2012.
this group of women >45 years of age to know that 13. Pettker C, Goldberg J, El Sayed Y. Methods for estimating
due date. Committee Opinion No 700. American College of
EAMA leads to more significant obstetric complication Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e150–4.
and neonatal morbidities. AMA is a risk factor for PIH, 14. Quinn JA, Munoz FM, Gonik B, Frau L, Cutland C, Mallett‑Moore T,
SGA newborn and antiphospholipid antibody syndrome et al. Preterm birth: Case definition and guidelines for data
in all 3 advanced age group. PIH, having CS, admission collection, analysis, and presentation of immunisation safety data.
of newborn to NICU/IMCU is more common to AMA Vaccine 2016;34:6047‑56.
15. Bouvier D, Forest JC, Blanchon L, Bujold E, Pereira B, Bernard N,
but same risk for EAMA and younger group. There is no
et al. Risk factors and outcomes of preterm premature rupture of
noted association between AMA and large for gestational membranes in a cohort of 6968 pregnant women prospectively
age newborn, having meconium staining and delivering recruited. J Clin Med 2019;8:E1987.
by classical cesarean section. Therefore, as obstetrics and 16. American College of Obstetricians and Gynecologists. Intrauterine
gynecologists, we should provide thorough counseling growth restriction. ACOG Practice Bulletin Clinical Management
Guidelines for Obstetrician‑Gynecologists No. 12. Washington,
of all couples, who seek to have a child in their late ages, DC. Obstet Gynecol 2019;133:e97‑109.
about the risks of AMA pregnancy. 17. Engle J. Age terminology during perinatal period. Am Acad
Paediatr 2004;114:e1920.
Financial support and sponsorship 18. Martinelli KG, Garcia ÉM, Santos Neto ET, Gama SG. Advanced
Nil. maternal age and its association with placenta praevia and
placental abruption: A meta‑analysis. Cad Saude Publica
2018;34:e00206116.
Conflicts of interest 19. Londero AP, Rossetti E, Pittini C, Cagnacci A, Driul L. Maternal
There are no conflicts of interest. age and the risk of adverse pregnancy outcomes: A retrospective
cohort study. BMC Pregnancy Childbirth 2019;19:261.
References 20. Lapaiboon M, Lumbiganon P, Intarut N, Mori R, Ganchimeg T,
Vogel JP et al., Advanced Maternal Age and Pregnancy Outcomes:
1. Natividad J. Teenage pregnanc in the Philippines: Trends, A multicountry assessment. BJOG 2014;121 (Suppl 1):49 56.
correlates and data sources. J ASEAN Fed Endocr Soc 2014;28:30. 21. Usta IM, Nassar AH. Advanced maternal age. Part I: Obstetric
2. Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, complications. Am J Perinatol 2008;25:521‑34.
Khashan AS. Advanced maternal age and adverse pregnancy 22. Cleary Goldman J, Malone F, Vidaver J, Ball R, Nyber D, Comstock
outcome: Evidence from a large contemporary cohort. PLoS One C et al. Impact of Maternal Age on Obstetric Outcome. Obstet
2013;8:e56583. Gynecol 2005;105:983 90.
3. Pokracka MR, Adrianowicz B, Plonka M, Danil P, Nowak M, 23. Osmundson SS, Gould JB, Butwick AJ, Yeaton‑Massey A,
Huras H. Evaluation of pregnancy outcome at advanced maternal El‑Sayed YY. Labor outcome at extremely advanced maternal
age. Maced J Med Sci 2019;7:1951‑6. age. Am J Obstet Gynecol 2016;214:362.e1‑7.
4. Carolan M, Frankowska D. Advanced maternal age and adverse 24. Odibo AO, Nelson D, Stamilio DM, Sehdev HM, Macones GA.
perinatal outcome: A review of the evidence. Midwifery Advanced maternal age is an independent risk factor for
2011;27:793‑801. intrauterine growth restriction. Am J Perinatol 2006;23:325‑8.
5. Philippine Statistics Authority (PSA) and ICF. Philippines 25. Pinheiro RL, Areia AL, Mota Pinto A, Donato H. Advanced
National Demographic and Health Survey 2017. Quezon City, maternal age: Adverse outcomes of pregnancy, a meta‑analysis.
Philippines, and Rockville, Maryland, USA: PSA and ICF; 2018. Acta Med Port 2019;32:219‑26.
6. Cunningham FG, Leveno KJ, Bloom SL, Dashe JS and Spong CY 26. Acda M, Comia L 3rd. Obstetrical and neonatal outcomes of
Williams Obstetrics. 25th ed. USA: McGraw Hill Education; 2018. singleton gestations among elderly Filipino Primigravids in a
7. Schwartz A, Many A, Shapira U, Rosenberg Friedman M, Yogev Y, tertiary government hospital – A five‑year review. PJOG 2018;42:2.

Philippine Journal of Obstetrics and Gynecology - Volume 45, Issue 5, September-October 2021 203