Under-age pregnancy refers to pregnancy in girls under the age of consent (16 years in the UK). The term ‘advanced maternal age’ applies to parturients aged 35 years or over. Some women are now able to conceive at an even later stage in life; mothers who give birth at the age of 45-49 years are said to be of ‘very advanced maternal age’, and those at the age of 50 years or over are of ‘extreme advanced maternal age’. The UK has one of the highest teenage pregnancy rates in Europe, while the incidence of pregnancy in older women is increasing in the developed world as a result of both maternal choice and infertility treatment.
Problems and special considerations
Under-age pregnancy
Those girls who are under-age when they present in pregnancy can be placed in the following groups:
• Those who have had normal antenatal care and have the full support of their family. This group usually have a parent available to give consent on behalf of the minor if that is felt appropriate, e.g. for epidural analgesia or for anaesthesia.
• Concealed pregnancy. This group may pose a problem with consent. Many will have had little or no antenatal care, and they may present to the hospital for the first time when they are in labour. Many present in advanced labour or to the emergency department with a life-threatening condition such as eclampsia, and there may not be time to find a parent or guardian before instituting treatment. Overall, this is an ‘at-risk’ group who often need considerable support, including epidural analgesia.
Hypertension, anaemia and poor nutritional status are more common in under-age mothers, and other risk factors may coexist, such as smoking and drug or alcohol abuse. Fetal risks include premature labour, fetal growth restriction, low birth weight and stillbirth.
Advanced maternal age
Miscarriage, fetal chromosomal abnormalities, multiple pregnancy, hypertension, ischaemic heart disease, diabetes, obstetric interventions, neonatal mortality and postpartum haemorrhage are more common in elderly mothers, who feature disproportionately in the reports of the Confidential Enquiries into Maternal Deaths.
Management options
In under-age mothers, it is important to remember at all times that the minor is the patient and must be involved in the decision making. In line with the Mental Capacity Act (in England and Wales), the child may take the decisions for her treatment if deemed competent. This may involve regional analgesia and/or anaesthesia. Ideally, the support and consent of a parent or guardian should be sought, although this may not be practical.
Elderly mothers require no special management other than an appreciation of the increased risks associated with advanced age. These women too should be considered an ‘at- risk’ group.
Key points
• Both under-age and elderly mothers are at-risk groups and have a higher incidence of complications.
• For minors, parental consent should be obtained when possible; if none is available, treatment should not be denied.
• Elderly mothers should be managed as routine, but the increased risk of complications should be remembered.
Further reading
Laopaiboon M, Lumbiganon P, Intarut N, et al.; WHO Multicountry Survey on Maternal Newborn Health Research Network. Advanced maternal age and pregnancy outcomes: a multicountry assessment. BJOG 2014; 121 (Suppl 1): 49-56.
Osmundson SS, Gould JB, Butwick AJ, Yeaton-Massey A, El-Sayed YY. Labor outcome at extremely advanced maternal age. Am J Obstet Gynecol 2016; 214: 362.e1-7.