INDUCTION INDICATION: ADVANCED MATERNAL AGE

DOCUMENT TYPE: REFERENCE TOOL

Level of Evidence

INDUCTION INDICATION: Maternal Age ≥ 40 years RECOMMENDATION: Offer Induction at ≥ 39 weeks gestation

Recommendation for labour induction: II-B Recommendation for timing of labour induction: II-B Recommendations for priority: II-B

Definition

The average age of childbirth is rising in developed countries. The definition of advanced maternal age for the purposes of this document is greater than or equal to 40 years of age. Studies report that advanced maternal age is associated with increased pregnancy risk for both mother and baby. Although the incidence of stillbirth at term is low, it is higher in women of advanced maternal age.1

Outcomes

There are known adverse perinatal outcomes for women who are of advanced maternal age. When compared to younger women, in older women there is increased risk for placental abruption, placenta previa, malpresentation, growth restriction, preterm and postdates delivery as well as postpartum hemorrhage. Even after controlling for medical co-morbidities, advanced maternal age is found to be associated with an increase in antenatal and intrapartum stillbirth.2 The relative risk of stillbirth for women ≥ 40 years of age, for both multiparous and primiparous women is 1.2 to 4.5. The cumulative risk of stillbirth in women 40 and older at 39 weeks gestation is similar to mothers 25 to 29 years at 41 weeks gestation3,4. The mechanism for increased risk of stillbirth in older mothers is as yet unknown.

Recommendations

Labour induction may be offered to mothers who are greater than or equal to 40 years of age at 39 weeks of gestation. Induction should be considered as a priority 3.

Supporting Documentation Required

 Prenatal sheets  Dating ultrasound (or information from fertility centre in the setting of IVF)  Documentation of existing age-related confounding factors and additional risk criteria

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DOCUMENT TYPE: REFERENCE TOOL

Weekly Cumulative Risk for IUFD + at Term by Maternal Age Group Maternal Age Group

GEST. AGE 25-29 35-39 40-44

37 0.0006 0.0011 0.0015

38 0.0014 0.0027 0.0055

39 0.0023 0.0040 0.0086

40 0.0038 0.0066 0.0151

41 0.0056 0.0096 0.0224

42 0.0088 0.0187 0.0523

Controlled for maternal race and smoking.

Stillbirth at Term in women of Advanced Maternal Age in the United States: When Could the Antenatal Testing Be Initiated? Bahtiyar, MO et al.Am J Perinatol 2008;25:301-4

References

1. Royal College of Obstetricians and Gynaecologists. SIP Opinion Paper No.34. 2016. 2. Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-8. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl 1):1-203. 3. Reddy U, Ko C, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Am J Obstet Gynecol 2006;195:764-70. 4. Wyatt P, Owolabi T, Meier C, Huang T. Age specific risk of fetal loss observed in a second trimester serum screening population. Am J Obstet Gynecol 2005;192:240-6. 5. Bahtiyar M, et al. Stillbirth at Term in women of Advanced Maternal Age in the United States: When Could the Antenatal Testing Be initiated? Am J Perinatol 2008;25:301-4. 6. Delbare, I., Verstaelen, H., Goetgeluk, S., Martens, G., De Backer, G., Temmerman, M. (2007) Pregnancy outcome in primiparae of advanced maternal age. European Journal of Obstetrics and Gynecology and Reproductive Biology. 135 p. 41-46 7. Heffner, L., Elkin, E., Fretts, R., (2003). Impact of labor induction, gestational age and maternal age on cesarean delivery rates. American College of Obstetrics and Gynecology. Vol. 102 (2) August. Pg. 287-293. 8. Jacobsson, B., Ladfors, L., Milsom, I., (2004) Advanced maternal age and adverse perinatal outcome. American Colleagoe of Obstetrics and Gynecology. Vol. 104 (4) October. Pg. 727-733. 9. Liu, K., Case, A. (2011) Advanced reproductive age and fertility. SOGC Clinical Practice Guideline. JOGC 269 (November 1165-1175). 10. Luke, B., Brown, M., (2007) Elevated risks of pregnancy complications andadverse outcomes with increasing maternal age. Human Reproduction. Vol. 22 (5) February pg. 1264-1272. 11. Johnson, J, Tough, S. (2012) Delayed Child-Bearing. SOGC Committee Opinion. JOGC 34(1) 80-93. 12. Rosenthal, A., Paterson-Brown, S., (1998) Is there an incremental rise in the risk of obstetric intervention with increasing maternal age? British Journal of Obstetrics and Gynaecology. 105 p. 1064-1069. 13. Royal College of Obstetricians and Gynaecologists (2013) Induction of Labour at term in older mothers. Scientific Paper, No. 34 p. 1-8

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DOCUMENT TYPE: REFERENCE TOOL

Version History DATE DOCUMENT NUMBER and TITLE ACTION TAKEN 23-Oct-2018 WW.05.11E18 Induction Indication: Advanced Maternal Approved at: Perinatal Best Practice Age Committee

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WW.05.11E18 Published Date: 15-Nov-2018 Page 3 of 3 Review Date: 15-Nov-2021 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.