Abstract

BACKGROUND/AIMS

The purpose of this current research was to evaluate the perinatal and neonatal outcomes among >35-year-old grand multiparous, multiparous, and primiparous pregnant females.

MATERIALS AND METHODS

In this study, a total of 156 patients who underwent pregnancy follow-up and gave birth in the obstetrics clinic between January 2018 and January 2024 were included. The participants were divided into 3 groups based on primiparous (single birth), multiparous (2-4 births), and grand multiparous (5 or more births). The age, parity, type of birth, presence of perineal tears, blood transfusion history, presence of gestational hypertension, and gestational diabetes during pregnancy were scanned retrospectively from the hospital database of the females analyzed in the research.

RESULTS

The mean body mass index of grand multiparous pregnant females was 27.4±3.1 kg/m², which was considerably larger than that of the other groups (p=0.032). The gravida number of grand multiparous pregnant females was 6 (5.7) and the parity number was 6 (5.5), which were found to be higher than in the other groups (p=0.012, p=0.008, respectively). The rate of perineal laceration was considerably higher in the primiparous pregnant group than in the other groups (p=0.021). When compared with regard to pregnancy and birth-complications, estimated blood loss volume and >1000 cc bleeding rates were shown to be considerably larger in primiparous-pregnancies than in other pregnancies (p=0.012, p=0.046, respectively). Neonatal intensive care unit need was observed tobe significantly greater in the primiparous pregnant groups than in the other groups (p=0.024).

CONCLUSION

In this current research we showed that grand multiparity (GM) has complication rates similar to other groups and is not a risk factor alone. Advanced maternal age may also be associated with difficulties associated with GM. Pregnancy monitoring and birth should be performed more frequently and carefully to reduce risks in this patient group.

INTRODUCTION

Grand multiparity (GM) is generally referred to the pregnant females having a parity of five or more.¹ Some previous studies showed that higher perinatal-mortality, postpartum-hemorrhage (PPH), cesarean section (C/S) rates, placenta-previa, antepartum-hemorrhage, diabetes mellitus, and iron deficiency-anemia, are all considerably higher in GM patients.^2-4 According to some research, there is no difference in the antepartum complication rate between grand multiparous-pregnancies and ordinary multiparous pregnancies.^{5, 6} Complications associated with GM are less common because GM is not common in developed countries due to socioeconomic and sociocultural factors. GM and its accompanying complications have become a problem and can cause maternal and newborn death and morbidity, especially in developing and underdeveloped countries.^7-10 Gestational diabetes mellitus (GDM), gestational hypertension (GHT), premature birth, and postpartum hemorrhage are among the most common pregnancy complications of grand multiparous females.^7-10 Studies have reported that the prevalence of these complications increases with maternal age.¹¹ In another study that considered maternal age as a separate risk factor in this respect, socioeconomic status and conditions that trigger cardiovascular disease were not excluded.¹² Advanced maternal age was independently linked with many GM problems.¹³ The purpose of this current investigation was to compare perinatal and neonatal outcomes between grand multiparous pregnant women aged 35 years and over and multiparous and primiparous pregnant women.

MATERIALS AND METHODS

The present research was constructed in a retrospective-observational design following the principles of the Declaration of Helsinki. Informed consent documents were obtained from each patient for the current investigation. This research was initiated after receiving ethics committee approval from Buca Seyfi Demirsoy Training and Research Hospital’s Ethics Committee (approval number: 2024/292, date: 29.05.2024). A total of 156 pregnant women, whose pregnancy follow-up was performed in the Buca Seyfi Demirsoy Training and Research Hospital, Clinic of Gynecology and Obstetrics and who gave birth in our clinic, from January 2018 to January 2024, were included in the current research. Depending on their parity, the subjects were split into 3 groups: grand multiparous (5 or more births), multiparous (2-4 births), and primiparous (single births). Fifty-two patients in each of the primiparous, multiparous, and grand multiparous groups were analyzed in the research. Females aged >35 years and having a history of singleton pregnancy were included in the study. No perinatal or neonatal risks were detected in the previous pregnancies of the women included in this study. Those <35 years of age, females who had not given birth for >24 weeks, females with multiple-pregnancies, females with consanguineous marriages, females with coagulation disorders, and females whose information was incomplete were not included in the research. The age of the females in the research, gravida, body mass index (BMI) at the time of pregnancy, parity, number of abortions, smoking status, gestational age, type of birth, presence of perineal tear, prenatal and postpartum-hemoglobin and hematocrit scores, postpartum hysterectomy background, hospital stay, blood transfusion background, presence of GHT, and GDM were scanned retrospectively from the hospital database and patient files. Regular cigarette use was defined as 10 cigarettes per day.¹⁴ Fetal congenital anomaly, 1^st and 5^th minutes Apgar scores, neonatal intensive care unit (NICU) history, birth weight data, and intrauterine fetal death history were evaluated. GDM was constructed according to the criteria established by the American Diabetes Association.¹⁵ GDM is confirmed if one or more of these plasma glucose levels meet or exceeds the specified thresholds.: Fasting: 92 x mg/dL (5.1 x mmol/L), 1h: 180 x mg/dL (10.0 x mmol/L), 2h: 153 x mg/dL (8.5 mmol/L). A 75 g oral glucose tolerance tests (OGTT) test is conducted at 24-28 weeks in pregnant women who have never had diabetes before, and plasma glucose levels are evaluated during the first and second hours of fasting. After a minimum of eight hours of fasting overnight, the OGTT should be performed in the morning. Based on the most recent recommendations from the American-College of Obstetricians and Gynecologists bulletin,¹⁵ GHT was diagnosed.¹⁶ Proteinuria and hypertension together are diagnostic criteria for preeclampsia. After the 20^th week of pregnancy, in females with formerly normal-blood pressure, GHT was defined as a systolic-blood pressure of no less than 140 mmHg or a diastolic-blood pressure of no less than 90 mmHg tested four hours apart or more. A systolic-blood pressure of 160 mmHg or greater or a diastolic-blood pressure of 110 mmHg or greater is considered severe hypertension. For the diagnosis of preeclampsia, females with hypertension must also exhibit proteinuria, which is defined as the presence of a minimum of 300 mg of protein in a 24-hour urine collection. Patients who satisfied the requirements for hypertension associated with preeclampsia but did not exhibit proteinuria or any severe additional complications were diagnosed with GHT.¹⁶ Hemoglobin values <11 g/dL were used to diagnose anemia.¹⁷ Delphicriterion was used to diagnose fetal growth restriction.¹⁸ A fetus’s death at >24 weeks’ gestation was referred to as fetal mortality. Estimated blood loss volume, postpartum-hemoglobin score, and presence of blood transfusion were evaluated in the evaluation of peripartum-hemorrhage. The expected blood loss of >1000 mL was considered excessive. Control hemoglobin levels were measured in all females approximately 12 hours after birth. The estimated volume of blood loss was measured by utilizing the pregnant females’s height, weight, and prenatal and postpartum hematocrit values.¹⁹ Blood transfusion indications were determined in terms of vital signs, estimated blood loss volume, and postpartum hemoglobin value <8 g/dL.¹⁹

Statistical Analysis

Statistical analysis was performed using SPSS 26.0 (IBM-Inc-Chicago-IL-USA). The distribution normality was measured with the Kolmogrov-Smirnov test and Shapiro-Milk test, ANOVA, or Wallis test on the basis of whether the data demonstrated normal-distribution. The Fisher’s exact and chi-square tests were employedin the categorical-data analysis. The quantitative-data of the patients were presented as mean ± standard deviation (minimum-maximum). The results were evaluated at a 95% confidence interval. The p-value, <0.05, was regarded as statistically significant. The post-hoc power analysis was performed using the G*Power 3.1 tool (Erdfelder-Faul-Buchner-Düsseldorf-Germany). A total of 144 was determined to be the required sample size.

RESULTS

The average age of the participants for this present research was found to be 38.1±2.5 and the average BMI was 26.2±3.8 kg/m². The average BMI of the grandimultiparous patients was; 27.4±3.1 kg/m², which was significantly higher than the BMI mean of the primiparous and multiparous patient groups (p=0.032). The mean gravida of the grand multiparous patients was 6 (5.7), and the parity mean was found to be 6 (5.5), which was significantly higher than the mean gravida and parity of the primiparous and multiparous patients (p=0.012, p=0.008; respectively) (Table 1).

The high rate of C/S in multiparous and grand multiparous pregnant females was attributed to the increase in the rate of previous C/S indications. In the primiparous group, one patient had cleft lip and palate, and one patient had umbilical hernia. In the multiparous group, one patient had cleft lip and palate, and one patient had syndactyly. In the grand multiparous group, one patient had trisomy 21. Two patients underwent hysterectomy due to uterine atony after vaginal birth. The rate of perineal laceration was significantly greater in the primiparous group than in the grand multiparous patients (p=0.015). ΔHb level was significantly greater in the primiparous group than in the other groups (p=0.016). When analyzed by comparing the pregnancy and birth complications, primiparous pregnancies had an estimated blood loss volume that was substantially larger than pregnancies that were multiparous (p=0.012). The >1000 cc bleeding rate was significantly greater in the primiparous patient group than in the grand multiparous patients (p=0.046) (Table 2).

The need for NICU was significantly greater in primiparous patients than in grand multiparous patients (p=0.024). Among primiparous patients, 8 (72.7%) patients requiring NICU had a history of vaginal birth. No significant differences were observed across the groups on the basis of Apgar (1^st minute) and (5^th minute) scores, birth weights, or fetal mortality rates (Table 3).

DISCUSSION

There were no notable differences observed in grand multiparous-pregnant females on the basis of perinatal and neonatal risks compared with other groups in the present study. The presence of perineal laceration estimated blood loss volume and NICU need were significantly higher in primiparous pregnant women. The mean BMI of grand multiparous pregnant women was significantly higher than that of the other groups. Many previous studies have evaluated the effects of GM in pregnancy. However, GM was not evaluated as an independent risk factor in these studies but was evaluated together with many risks, including age, socioeconomic-status, and smoking status.^20-22Only women aged >35 years were included in the present study in all groups because the majority of issues observed in grand multiparous pregnancies might be linked to older mothers. Since all patients were >35 years old, we believe that age differences between the groups had little bearing on pregnancy problems, even if a substantial difference in gravida and parity was seen between them. It is particularly important to evaluate the increased risks of GM and prenatal and postnatal complications, independent of age, smoking, socioeconomic status, and ethnic background. Previous studies have reported that the prevalence of complications considered to be linked with GM, (e.g., placenta-previa, preeclampsia, and PPH) increases as maternal age increases.^{11, 12} It is difficult to distinguish whether the complications in these patients are associated with advanced age or GM because grand multiparous females are likely to be older.^{12, 23} In previous research, Alsammani et al.²¹ reported that many complications were reduced in young grands multiparous females compared with older grand-multiparous patients, and many complications increased when compared with primiparous and multiparous patients who were of the same age. To make this distinction, a preliminary study was conducted on women >35 years of age in the current investigation, and the risks associated with the age factor that might occur between the groups were eliminated. Thus, a suitable environment is provided to evaluate only the risks associated with parity. Studies have reported that a low socioeconomic status is linked to more births.^{5, 24} Many previous studies investigating the relationship between GM and pregnancy outcomes have reported a lack of prenatal care.^{25, 26} The socioeconomic status and prenatal care parameters of the patients could not be evaluated in this study due to insufficient data. In the literature, several studies have reported that low birth weight newborns are more likely to have a history of GM.^{5, 21} There were no noticeable differences in the rates of low birth weight infants between the groups in the present study. Previous studies have shown that the prevalence of hypertensive pregnancy disorders as a pregnancy complication is elevated in grand multiparous patients compared with other patients.²⁷ No increased risk of GHT and preeclampsia was detected in grand multiparous patients compared with the other groups in the present study. It has been reported in the literature that postpartum bleeding is a common complication in grand multiparous patients.^{28, 29} It is generally believed that an increase in the number of births causes uterine atony, leading to postpartum hemorrhage.³⁰ Unlike the literature data, the estimated blood-loss volume in primiparous pregnancies was substantially larger than that in multiparous pregnancies in the current research when evaluated in terms of pregnancy and delivery problems. The bleeding rate of >1000 cc was significantly greater in the primiparous group than in the grand multiparous group. The reason for this was considered to be a significantly higher rate of perineal laceration in primiparous pregnant females in the present investigation and the bleeding caused by this. Previous studies in the literature have shown that the postpartum hemogram values of grand multiparous patients are lower.^{27, 29} Regarding postoperative hemoglobin levels, no statistically significant differences were observed between the groups in this study. Studies in the literature have reported that the Apgar score is lower in grand multiparous females.^{3, 21} Al-Shaikh et al.³¹ conducted a study on grand multiparous patients and reported that they had similar perinatal and neonatal-risks when compared to other groups after adjusting for age. No significant differences were detected in this present investigation between the 1^st and 5^th-minute Apgar scores between the groups. However, the requirement for NICU was significantly higher in the primiparous patient group. It is considered that this might have occurred because of fetal distress secondary to prolonged labor in primiparous patients. Because of the age group selected in this study, eliminating the effect of age risk, which is known to be a significant risk factor for perinatal and neonatal outcomes, and focusing only on parity might be regarded as this current study’s strength.

Study Limitations

The most important limitation of this study was that the data collected were restricted to what could be found in the records of patients because it was a retrospective study. Another limitation was that no data were available on factors that affect pregnancy outcomes, such as socioeconomic status and pre-pregnancy care.

CONCLUSION

Our study showed that GM pregnancy is not an independent risk factor; rather, perinatal and neonatal complication rates are comparable to those of nulliparous and multiparous pregnancies. We believe that poor prenatal care, low socioeconomic status, and advanced age may be linked to a number of GM-related complications. Pregnancy monitoring and birth should be performed more frequently and carefully to reduce the risks in these patients.