WHO IS THE ELDERLY PRIMIGRAVIDA?
K. H. LEE, M.B., B.S., M.R.C.O.G.
Senior Lecturer in Obstetrics and Gynaecology
University of Hong Kong
Who is the elderly primigravida? That is the question that still remains not
satisfactorily answered even to-day.
The majority of writers apply the term to a woman over the age of 35 years
who is pregnant for the first time (Nathanson, 1935, Arnot and Nelson, 1950; Waters
and Wager, 1950; Dennen and Ainslie, 1951; Posner and Luftman, 1952; Arthur and
Kaltreider, 1956; Macdonald and MacLennan, 1960; O’Sullivan, 1960; Booth and
Williams, 1964). In 1958, the Council of the International Federation of Gynaecology
and Obstetrics also recommended that the age of 35 should be accepted as the inter-
However, Donald (1964) thinks that to include all women going through their
first pregnancy over the age of 35 years is widening the definition too far. He main-
tains that many primigravidae between the ages of 35 and 40 years run a perfectly
normal obstetrical course and these in no sense deserve to be classed as elderly. Both
Miller (1931) and Nixon (1931) in their papers discuss only women over the age of 40.
On the other hand, Baird, Hytten and Thomson (1958) have shown evidence of
a decline of physiological effciency from the age of 25 onwards. Other writers
(Rucker, 1935; Lock et al., 1959; Young, 1963) also suggest that from 30 years of
age, a primigravida becomes elderly. Dutta (1948) in India goes even further and
takes 26 years as the lower age limit for definition. The Confidential Enquiries into
Maternal Deaths in England and Wales 1959-1960 (1963) showed that primigravidae
over the age of 30 were at a higher risk than their younger sisters. The British
Perinatal Mortality Survey in 1958 also confirmed an increasing perinatal mortality
with rising maternal age after 30 years (Butler and Bonham, 1963).
A. clinical study of all primigravidae delivered in the same unit over a period
of three years has been undertaken to find out the age above which a primigravida is
at higher risks.
MATERIAL FOR STUDY
All primigravidae delivered in the Obstetric ‘A’ Unit of Queen Elizabeth Hospital,
Hong Kong, from 1965 to 1967 were taken for study. Over these three years, the
total number of primigravidae was 3,567. They were classified into three age groups
as shown in Table I. Fifteen patients were over the age of 40 and the highest age
in this series was 46 years. The complications of pregnancy and labour, foetal
presentations, mode of delivery and mortality rates were compared among the three
52 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 22, 1970
Age (years) NtM-?dMT Percentage
-._____._. __~~--. .__-_-.-
30 and under 3,078 86.3
31-35 338 9.5
36 and above 151 4.2
TABLE I-Age Groups of the 3,567 Primigravidae
Complications of Pregnancy
As shown in Table II, primigravidae aged 31-35 years were associated with a
significantly higher incidence of toxaemia, diabetes mellitus, uterine fibromyoma,
accidental haemorrhage and placenta praevia when compared with younger primigra-
vidae. Those aged 36 and above also had more toxaemia and uterine fibromyoma.
Complication \ 30 and under Sl - 35 36 and above
Anaemia 326 (10.6%) 1 46 (13.6%) 15 ( 9.9%)
Cardiac disease 27 ( 0.9%) 3 ( 0.9%) 0
Diabetes mellitus 1 ( 0.03%) 3”“*( 0.9%) 0
Thyrotoxicosis 14 ( 0.5%) 2 ( 0.6%) 1 ( 0.7%)
Tuberculosis of spine or hip 7 ( 0.2%) 1 ( 0.3%) 0
Uterine fibromyoma 6 ( 0.2%) 6”#‘( 1.8% 1 2 *“( 1.3%)
Ovarian cyst 6 ( 0.2%) I ( 0.3%) 1 ( 0.7%)
Toxaemia 366 (11.9%) 63”““(18.6%) 29 ** (19.2%)
Twins 30 ( 1.0%) 5 ( 1.5%) 1 ( 0.7%)
Hydramnios 11 ( 0.4%) 1 ( 0.3%) 0
Contracted pelvis 165 ( 5.4%) 16 ( 4.7%) 18 (11.9%)
Accidental haemorrhage 3 ( 0.1%) 3 ““( 0.9%) 0
Placenta praevia IO ( 0.3%) 4 “( 1.2%) 2 ( 1.3%)
TABLE II-Complications of ,Pregnancy
* P = < 0.05
** P = < 0.01
*** P = < 0.001
WHO IS THE ELDERLY PRIMIGRAVIDA?
They also had a higher incidence of contracted pelvis because radiological pelvimetry
was more commonly performed in this group. The differences in the rate of anaemia,
thyrotoxicosis and twins among the three groups were not statistically significant.
Foetal Presentation and Position
In Table III, the presentations and positions of the total 3,603 babies are shown.
Persistent occipito-posterior position was more common in primigravidae over the age
of 30 and the difference was significant. The incidence of breech and other malpre-
sentations was not higher in the older primigravidae.
w 30 and under / Sl-$5 36 and above
_- ~ -. . -
Vertex OA I 2,822 (90.8%) 305 (88.9%) 135 (88.8%)
Vertex OP 108 (3.5%) 19”( 5.5%) lOS( 6.6%)
Breech 166 ( 5.3%) 17 ( 5.0%) 5 ( 3.3%)
Face 5 ( 0.2%) 0 1 ( 0.7%)
Shoulder 3 ( 0.1%) 0 1 ( 0.7%)
Compound 4 ( 0.1%) 2 ( 0.6%) 0
TABLE III-Foetal Presentation and Position
* P = < 0.05
Complications of Labour
These are listed in Table IV. Primigravidae aged 31-35 were found to require
surgical induction of labour more commonly and their labour was more often prolonged.
However, postpartum haemorrhage and manual removal of placenta were apparently
less frequent although the differences were not statistically significant.
Method of Delivery
The methods of delivery of the 3,603 babies are shown in Table V. Primigravidae
over the age of 30 had significantly fewer spontaneous deliveries and required more
Caesarean section. This trend was even more marked in the group aged 36 and above.
Bowever, the incidence of vacuum extraction and forceps delivery was only slightly
higher in the two older age groups with no significant difference.
64 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 22, 1970
G$maplic&~--+---,___G-rwp 30 and undo 31-85 ) 36 and above
. _-_ -.. “_~..- -- - -- _-
Surgical induction 93 (3.0%) 20”‘(5.9%) 7 (4.6%)
Prolonged labour 143 (4.7%) 27”” (8.0%) I 9 (6.0%)
Prolapse of cord 10 (0.3%) 1 (0.3%) j 0
Postpartum haemorrhage 54 (1.8%) 4 (1.2%) 1 0
Manual removal of placenta 36 (1.2%) 2 (0.6%) j 0
TABLE IV-Complications of Labour
hg=i 30 and under 3i- 55 36 and above
--.~~-__._ ~~ ..__ -. :
Spontaneous 2,251 (72.4%) 205”‘“(59.8%) 73”“” (48.0%)
Vacuum extraction 285 ( 9.2%) 33 ( 9.6%) 19 (12.5%)
Forceps 187 ( 6.0%) 20 ( 5.8%) 13 ( 8.6%)
Assisted breech 118 ( 3.8%) 8 ( 2.3%) 2 ( 1.3%)
Caesarean section 267 ( 8.6%) 77**“(22.5%) 45”“‘(29.6%)
***P = < 0.00l
TABLE V-Method of Delivery
Table VI shows the maternal and perinatal mortality of the three age groups.
There were altogether six maternal deaths in the whole series. Four occurred
in the youngest age group, the causes of which were cardiac disease in two, eclampsia
in one and septicaemia in one. The other two deaths were among those aged 31-35
years and were caused by accidental haemorrhage in one and amoebiasis in the other.
However, the difference in the maternal mortality rates was not statistically significant.
The perinatal mortality rates in the two older age groups appeared higher but
the difference was not significant.
WHO IS THE ELDERLY PRIMIGRAVIDA?
I._ Age Gruup 36 and
Hortality l--.-, 30 and under I 31-85 above
Maternal mortality 4(1.3 per 1000) 1 2(5.9 per 1000) 0
Stillbirth 32(1.0~~) / 10(2.9%) 3(2.0%)
Neonatal death 46(1.5%) 3(0.9%) 3(2.0%)
Perinatal mortality 77(2.50/o) / 13(3.8%) 6(4.0%)
TABLE VI-Maternal and Perinatal Mortality
Twenty-seven babies in the youngest group were born with congenital malforma-
tions (0.9%). The incidences for the older patients were not significantly higher, being
0.6% in the group aged 31-35 and 1.5% in the group aged 36 and above (two cases
in each group).
Many published reports on elderly primigravidae did not compare the results
with a control series of younger women. Others took a control series from a different
period for comparison. Hence, the lines of management might have been different
and the results not entirely comparable.
In the present series, all the three age groups of primigravidae were delivered
in one unit within the same period of three years. Moreover, in this unit, primigra-
vidae under 36 years were not given special attention. Therefore, the significant
difference in the results between the group aged 31-35 and the group aged 30 and
under truly reflected the effect of age alone.
As expected, older patients suffered more from toxaemia of pregnancy. Whereas
other writers (Nixon, 1931; Young, 1963 ; Booth and Williams, 1964) found an
increased incidence of toxaemia only after the age of 40, in this series toxaemia was
considerably more common even in the group aged 31-35.
The increased frequency of uterine fibromyoma in the elderly patients was in
agreement with the findings of Nixon (1931) and Young (1963). Again, the increase
in frequency was significant after the age of 30.
Waters and Wager (1950) reported a higher incidence of antepartum haemor-
rhage among elderly primigravidae but O’Sullivan (1960) and Young (1963) failed to
confirm it. In this series, however, both accidental haemorrhage and placenta praevia
were significantly more common in the group aged 31-35.
There was no difference in the incidence of other complications of pregnancy
such as cardiac disease, twins and hydramnios. The same experience has been reported
by Nixon (1931), Waters and Wager (1950) and Booth and Williams (1964).
66 THE BULLETIN OF THE HONG KONG MEDICAL ASSOCIATION VOL. 22, 1970
In agreement with other writers (Miller, 1931; Nixon, 1931, Nathanson, 1935;
Arnot and Nelson, 1950; O’Sullivan, 1960), persistent occipito-posterior position was
more common in elderly primigravidae and in this series, those aged 31-35 showed
the same increased incidence. Whereas others reported a higher incidence of breech
presentation as well, this was not confirmed in the present series.
Baird (1958) had an induction rate of 39 per cent. In this series, the rate of
surgical induction was higher among primigravidae aged 31-35. In this same group,
the incidence of prolonged labour was increased. Stewart and Bernard (1954) found
that labour became more difficult with advancing age and suggested that this might
be due to increased rigidity of the pelvis and less reserve of power in the uterus. It
was not surprising that the rates of both induction and prolonged labour were not as
high in the group aged 36 and above as Caesarean section was resorted to more
Primigravidae after the age of 30 were found to have fewer spontaneous
deliveries with a corresponding rise in the Caesarean section rate. The differences
were highly significant. However, the increased forceps rate reported by others
(Miller, 1931; Nixon, 1931; O’Sullivan, 1960; Booth and Williams, 1964) was not
experienced in the present series.
Opinions differ regarding whether elderly primigravidae are more prone to com-
plications of the third stage. Although Nixon (1931) found a higher incidence, the
results in this series showed no difference in the incidence of postpartum haemorrhage
or that of manual removal of placenta. This finding is in agreement with most other
writers (Waters and Wager, 1950; O’Sullivan, 1960; Young, 1963).
Donald (1964) points out that the risk of maternal mortality in the elderly
primigravida is only slightly higher than in younger women. The apparently higher
maternal mortality rate among those aged 31-35 in this series was not statistically
A study of the perinatal mortality rate in the reported series of elderly primi-
gravidae has revealed that it was considerably increased in early reports (Miller,
1931; Nathanson, 1935; Amot and Nelson, 1950), whereas in recent reports it was not
much raised (Arthur and Kaltreider, 1956; O’Sullivan, 1960; Booth and Williams,
1964). In the present series, the perinatal mortality rate was apparently higher in
those above the age of 30 but the differences were not statistically significant. These
results lend support to the belief of Donald (1964) that elderly primigravidae, properly
supervised, are capable of safe and successful pregnancy.
SUMMARY AND CONCLUSIONS
A study was made of all the 3,567 primigravidae delivered in the Obstetric `A’
Unit of Queen Elizabeth Hospital, Hong Kong, over a period of three years, 1965-1967.
They were classified into three age groups, namely 30 years and under, 31-35 and
WHO IS THE ELDERLY PRIMIGRAVIDA?
Primigravidae over the age of 30 were found to be associated with a higher
incidence of complications of pregnancy such as toxaemia, diabetes mellitus, uterine
fibromyoma, accidental haemorrhage and placenta praevia. Persistent occipito-posterior
position was more common in these women. They more frequently required surgical
induction and labour was more often prolonged. Spontaneous vaginal delivery was
much less likely than in younger primigravidae with a corresponding rise in the
Caesarean section rate. These differences were all statistically significant.
Although the mortality rates showed no significant differences among the three
age groups, primigravidae over the age of 30 years deserve to be classed as elderly
in view of the higher incidence of complications. They deserve special attention and
should certainly be supervised in well-equipped hospitals.
I am grateful to Dr. H. Abdullah, Obstetric and Gynaecological Specialist, Queen
Elizabeth Hospital, Hong Kong, for permission to study the cases under his care. I
thank Professor Daphne Chun for her helpful suggestions.
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