European Journal of Cardiovascular Medicine

Motherhood is considered one of the most important milestones in a woman’s life, yet it is also associated with significant physiological, psychological, and social adjustments. The age at which women bear children has undergone remarkable changes in recent decades. Historically, childbearing was concentrated in the younger reproductive years, but with shifting social norms, educational pursuits, professional aspirations, delayed marriages, and advances in assisted reproductive technologies (ART), pregnancy at advanced maternal age is becoming increasingly common worldwide [1,2]. Advanced maternal age is conventionally defined as pregnancy occurring at or beyond 35 years, although some studies have used slightly varying thresholds [3]. Pregnancies in this age group are categorized as high-risk because of their association with adverse maternal and perinatal outcomes, making it a significant concern in modern obstetric practice [4].

Elderly gravidae can be broadly divided into elderly primigravida—women experiencing their first pregnancy at or beyond 35 years—and elderly multigravida—women with previous pregnancies who conceive again at this age. The two groups differ in their background characteristics, physiological adaptations, and obstetric challenges. Elderly primigravidae often conceive after years of infertility treatment, lifestyle modifications, or ART procedures. These women may present with heightened anxiety, increased antenatal surveillance, and higher likelihood of obstetric interventions [5]. On the other hand, elderly multigravidae are more likely to have comorbid conditions related to multiparity such as uterine scarring, anemia, or pelvic floor disorders, and may also face complications due to cumulative reproductive stress [6]. Therefore, it becomes crucial to evaluate and compare outcomes between these two subgroups rather than generalizing all elderly pregnancies together.

Maternal complications in advanced maternal age pregnancies are well documented. Elderly primigravidae are particularly prone to hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), and prolonged or obstructed labor, often necessitating cesarean deliveries [7]. Several studies have reported higher rates of elective and emergency cesarean sections in this group, partly due to medico-legal concerns, patient preferences, and obstetrician bias, in addition to genuine clinical indications [8]. Conversely, elderly multigravidae, though having a lower threshold for spontaneous labor onset and vaginal delivery, are not without risks. They tend to have higher incidences of antepartum hemorrhage, malpresentations, grand multiparity-related uterine atony, and postpartum hemorrhage (PPH) [9]. These complications highlight the divergent pathways through which age and parity influence maternal morbidity.

Perinatal outcomes are also significantly affected by advanced maternal age. Advanced maternal age has been associated with increased risks of preterm birth, intrauterine growth restriction (IUGR), low birth weight, and stillbirths. Neonatal intensive care unit (NICU) admissions are also reportedly higher among babies born to elderly mothers [10]. In elderly primigravidae, adverse neonatal outcomes are often secondary to complications like pre-eclampsia, prematurity, and iatrogenic early deliveries. From a clinical standpoint, understanding whether elderly primigravidae or elderly multigravidae experience worse maternal and perinatal outcomes is vital for risk assessment and counseling. Elderly primigravidae often undergo more antenatal monitoring, earlier hospital admissions, and a lower threshold for cesarean section, whereas elderly multigravidae may be under-monitored due to familiarity with previous pregnancies, which may mask emerging complications. These differences could lead to variation in outcomes, making comparative evaluation both clinically and academically relevant. Given the paucity of literature directly comparing elderly primigravidae and multigravidae within the same population, especially in the Indian context, this study is designed to fill that gap. By systematically evaluating maternal and perinatal outcomes across the two groups, this research aims to highlight specific risks associated with each subgroup, inform evidence-based obstetric care, and aid in counseling women who conceive later in life.

Study design: prospective observational study.

Place of study: ESIC Medical College, Joka, Kolkata.

Period of study: February 2021- June 2022 (18 month).

Study Population: Women attending the antenatal clinic and labour room of ESIC Joka, Kolkata.

Study Variables:

• Age
• Reasons For Late Conception
• Mode Of Conception
• Late Pregnancy Complication
• Time Of Birth
• Mode Of Delivery
• Post Partum
• Complications

Sample size: 115 elderly primigravida (≥35 years) and elderly multigravida (<35 years) women.

Inclusion Criteria:

• Pregnant women aged ≥35 years (elderly gravida).
• Pregnant women aged <35 years (young gravida) for comparison.
• Women attending antenatal clinic or labour room at ESIC Medical College, Joka.

Exclusion Criteria:

• Women with multiple pregnancies.
• Women with known systemic illnesses prior to conception.
• Women unwilling to participate or lost to follow-up.

Statistical Analysis: The collected data were entered into Microsoft Excel and analyzed using Statistical Package for the Social Sciences (SPSS) version XX (IBM Corp., Armonk, NY, USA). Descriptive statistics such as mean, standard deviation, and proportions were used to summarize demographic and clinical variables. Categorical variables were compared between groups using the Chi-square test or Fisher’s exact test, while continuous variables were analyzed using the independent sample t-test or Mann–Whitney U test, as appropriate. A p-value of less than 0.05 was considered statistically significant.

Table 1: Distribution of Elderly and Young Gravida by Age and Parity

Table 2: Reasons for Late Conception among Elderly Primigravida

Table 3: Mode of Conception among Elderly and Young Primi-gravida

Table 4: Late Pregnancy Complications among Elderly and Young Multigravida

Table 5: Time of Birth and Mode of Delivery among Elderly and Young Primigravida

Table 6: Postpartum Complications among Elderly and Young Primigravida

Figure 1: Comparison of Birth Weight between Elderly and Young Gravida

Figure 2: Comparison of Maternal and Perinatal Outcomes between Elderly and Young Primigravida

In this study of 230 participants, 115 were elderly gravida and 115 were young gravida. Among young gravid women, the majority were aged 21–25 years (68.7%), followed by 26–29 years (31.3%). In contrast, all elderly gravid women were aged ≥30 years, with the largest proportion between 30–35 years (67%), followed by 36–40 years (24.3%) and >40 years (8.7%). Primigravida constituted 22.6% and multigravida 77.4% among elderly women, whereas in the young group, primigravida and multigravida were nearly equally distributed (47% and 53% respectively).

Among the 26 elderly primigravida, the most common reason for late conception was a history of subfertility (53.84%), followed by bad obstetric history (26.92%), higher education (23.30%), and late marriage (19.23%).

In our study, spontaneous conception was observed in 12 (46.15%) elderly primigravida compared to 50 (92.59%) young primigravida, which was statistically significant (p = 0.001). Ovulation induction was required in 6 (23.07%) elderly primigravida versus 3 (5.55%) young primigravida (p = 0.001). Similarly, conception by in vitro fertilization (IVF) was noted in 8 (30.7%) elderly primigravida compared to only 1 (1.85%) young primigravida, with the difference being highly significant (p = 0.001).

Elderly multigravida showed higher rates of PROM (21.43% vs. 4.16%, p = 0.01) and chronic hypertension (25% vs. 4.16%, p = 0.003), both statistically significant. Anemia was also common in both groups but slightly lower in elderly multigravida (69.64% vs. 85.25%, p = 0.05). Other complications such as GDM (64.29% vs. 52%, p = 0.20), HDP (50% vs. 54.33%, p = 0.67), PPROM (17.86% vs. 22.83%, p = 0.52), obstetric cholestasis (30.6% vs. 35.41%, p = 0.58), IUGR (32.14% vs. 39.5%, p = 0.42), and abruption (14.29% vs. 4.16%, p = 0.80) were comparable between elderly and young multigravida without statistical significance.

In elderly primigravida, 77.7% delivered at term and 22.2% preterm, compared to 88.8% term and 11.1% preterm in young primigravida, with no significant difference (p = 0.31). Cesarean section was performed in 55.5% of elderly and 48.1% of young primigravida, while vaginal delivery occurred in 44.4% and 51.8% respectively (p = 0.62).

Wound infection was significantly higher in young primigravida (55.5%) compared to elderly primigravida (5.5%, p = 0.0005). Fever was noted in 11.1% of cases in both groups (p = 1). Psychosis occurred in 1 (1.8%) young primigravida, while none was reported in the elderly group. No cases of lactation failure or convulsions were observed in either group.

The literature on advanced maternal age by disentangling outcomes for elderly primigravida and multigravida. The markedly higher reliance on assisted conception among elderly primigravida (ovulation induction 23.07%, IVF 30.7%) versus young primigravida (5.55% and 1.85%, respectively) mirrors population trends of delayed childbearing and age-related subfertility, consistently described by Sauer and colleagues and by demographic syntheses highlighting postponement of parenthood and greater ART use in older mothers [11,12]. Although classical reviews link advanced maternal age with increased hypertensive disorders, GDM, and caesarean delivery [13,14], our elderly primigravida showed only a non-significant excess in caesarean rate (55.5% vs. 48.1%) and no significant difference in preterm birth (22.2% vs. 11.1%), suggesting that intensive antenatal surveillance and selective intervention may attenuate some age-associated risks in carefully managed settings [15]. Among multigravida, we observed significantly higher PROM (21.43% vs. 4.16%) and chronic hypertension (25% vs. 4.16%) in the elderly group. Elevated baseline cardiovascular risk and vascular remodeling with age could plausibly underlie the chronic hypertension signal, aligning with reports that maternal comorbidity burdens rise with age. The PROM excess contrasts with the largely neutral associations for membrane complications in some series, but could reflect parity-related cervical change, prior instrumentation, or cohort-specific factors; comparable rates of PPROM, IUGR, and HDP between elderly and young multigravida in our data further support heterogeneity across populations [16]. Notably, anemia was numerically lower in elderly than in young multigravida (69.64% vs. 85.25%, p=0.05), diverging from resource-limited settings where nutritional depletion and short inter-pregnancy intervals drive anemia in higher-parity, older women; programmatic iron–folate coverage and case-mix differences may explain this pattern [17]. The postpartum signal of substantially more wound infection in young versus elderly primigravida (55.5% vs. 5.5%) is counterintuitive given age-linked surgical risk and likely reflects small-cell instability, differential intrapartum factors or unmeasured confounders (BMI, glycemic status, antibiotic timing) rather than a protective effect of age per se [18]. Broadly, our results resonate with prior work showing that advanced maternal age elevates certain risks—particularly medical comorbidity and operative delivery—yet the magnitude and profile differ by parity, healthcare context, and management intensity [19]. These comparisons underscore the need for parity-stratified counseling: elderly primigravida merit preconception optimization and realistic discussions about ART and operative delivery, while elderly multigravida require vigilant screening for chronic hypertension and individualized strategies to mitigate membrane complications—within a framework that recognizes that not all age-associated risks are inevitable and many are modifiable with protocolized care [20].

In conclusion, this study shows that elderly gravida face unique maternal and perinatal risks compared to younger women. Elderly primigravida required more assisted conception and had higher cesarean rates, while elderly multigravida were more prone to PROM and chronic hypertension. Other complications such as anemia, GDM, HDP, and IUGR were comparable between groups. Though wound infection was unexpectedly higher in young primigravida, the overall comorbidity burden was greater among the elderly.

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