Grand multiparity hi[12915]

Obgyn, pregnancy

1. Grand multiparity . By: Modhi A Alhussinan Ob/ Gyn KSMC

2. What is it? Live births and stillbirths ≥20 weeks of gestation. GREAT grand multiparity = ≥10. The condition of a woman who has had five or more previous pregnancies. >5

3. History p 3

4. - For several decades, grand multiparity has been viewed with great caution. - Grand multiparity has almost disappeared in western countries due to advancements in family planning. - However, family planning is not welcome in some region because of cultural, religious or other social reasons.

5. The Effect of Parity on Maternal Mortality

6. Reasons for Rising Mortality Risk with Increasing Parity “Wear and Tear” from prior pregnancies Increasing Maternal Age Associated socio-economic factors

7. Pregnancy Wear and Tear Nutrient depletion Iron drain from pregnancy and lactation Calcium and others Uterine Damage Myometrial thinning and fibrosis → Dysfunctional labour Both hypertonic and hypotonic uterine activity Unpredictable response to oxytocic agents Risk of uterine rupture Endometrial thinning and morbid adherence of the placenta → Placenta previa and also Retained placenta and PPH

8. Pregnancy Wear and Tear (2) Abdominal Wall, Genital Tract and Pelvic Floor Spherical uterus → unstable lie and malpresentation Precipitate deliveries and genital tract injury Uterovaginal prolapse and urinary incontinence Other Sites Problems with pelvic stability Back problems Varicose veins and Haemorrhoids Metabolic Increasing birth weight due to a variety of causes Sometimes increasing maternal weight

9. The Effects of Increasing Maternal Age Increased risk miscarriage and aneuploidy Increasing age of eggs Risk of miscarriage is 1:10 at 20 but 1:3 at 40 Increased rates of multiple pregnancy An effect of increasing FSH which ripens >1 follicle Many Diseases Diabetes Hypertension Coronary artery disease

10. Associated Socio-Economic Factors Poverty Illiteracy Smoking, alcohol & drug abuse Poor Access to Health Care War and Famine Domestic abuse etc.

11. Common Problems of High Parity Unstable lie and malpresentation Dysfunctional Labour Precipitate delivery Uterine atony Obstetric Haemorrhage Placenta previa PPH Uterine Rupture

12. Management of the Grande Multipara Take a careful history – past obstetric history Optimise HB and iron stores Increased surveillance and screening in pregnancy Check carefully presentation at each visit >36 weeks “Watch and wait” in labour Use oxytocics with caution Active management of the 3 rd stage of labour Prevention of High Parity Family Planning Starts with the first pregnancy!

13. What studies say? Almost similar outcomes. p 13

14. GRAND MULTIPARA: STILL A MAJOR RISK FACTOR? Multiparty has always been considered as a factor for poor maternal and neonatal outcome . It has often been described as a risk factor for variety of obstetric complications. Grandmultiparity associated with medical complications like anaemia , diabetes and hypertension. Higher rates of caesarean section and incidence of obstructed labour and rupture uterus. Complications like hypertension, diabetes mellitus, malpresentations , anaemia , difficult labour , post partum haemorrhage , increased risk of operative delivery have often been seen associated with multiparity . Our study showed most multiparous patients came to the hospital for delivery without any antenatal investigations and check up done before. Grand multipara tends to be older, poorer and less likely to have accessed prenatal care. Grand multipara was associated with low socioeconomic status and education and poorer prenatal care.

15. Pregnancy Outcome in Grand and Great Grand Multiparity –Qatar Grandmultiparity is associated with a long list of complications, which include, preterm labour , anemia, pendulous abdomen, malpresentation , preeclampsia, placenta praevia and abruptio . Labour among grandmultiparous patients is regarded as a high risk labour because of uterine atony, postpartum hemorrhage, obstructed labour , ruptured uterus and higher incidence of operative delivery because of abnormal position and big baby and maternal exhaustion. Macrosomia also predisposes women to severe postpartum hemorrhage and vaginal lacerations . In one report, birth weight greater than 4000 g approximately doubled the risk of maternal blood loss greater than one liter. In another review, vaginal delivery of a macrosomic infant that was complicated by shoulder dystocia resulted in more lacerations requiring repair Both groups were comparable with regard to gestational age at delivery. However, great grand multiparous women had significantly fewer antenatal visits compare to the multiparous. This may be explained by the observations that multiparous patients who have had no problems in previous pregnancies often delay seeking medical care. They concluded that with high socio-economic state and high standard of antenatal care extreme grand mutliparity does not carry any added special obstetric or perinatal risk.

16. Maternal and fetal outcomes in grand multiparous women Several studies have provided data concerning the risk of grand multiparity for both mother and fetus. However, grand multiparity does not necessarily lead to significant additional maternal, fetal, or neonatal complications in high-income countries where access to high quality healthcare is available. The assessed maternal parameters include: age, marital status, education and employment as measures of socioeconomic status, # of prenatal visits, and pregnancy and labor complications. Fetal outcomes assessed were: birth wtight , Apgar score, acidosis, intracranial hemorrhage, early cerebral signs, infections, malformations, and mortality as measures of perinatal care. Grand multiparous are older, unmarried or divorced, less educated, unemployed, and have received less prenatal care than the control group; these differences were significant . Although labor complications were similar between the two groups, the cesarean delivery rate was significantly higher in group 1 compared with group 2 (13.1% vs 8.2%; P=0.037). Mean duration of labor was similar between the two groups, but prolonged labor of more than 24 hours was more frequent in group 1. Mean birth weight was significantly lower for neonates born to grand multiparous women compared with multiparous women (3237±568 g vs 3424±621 g; P=0.000). => greater number of perinatal late fetal deaths. I These studies concluded that with improved socioeconomic status and a high standard of prenatal care, grand multiparity does not necessarily carry special obstetric or perinatal risk.

17. p 17 Nigeria

18. Pregnancy outcomes in the two groups did not show any statistically significant difference except for the higher occurrence of fetal macrosomia and cephalopelvic disproportion among the grand multiparae , which differs from reports in earlier studies.  [4]  This was probably due to good antenatal care. The higher occurrence of fetal macrosomia and cephalopelvic disproportion among the grand multiparae was probably due to the increase in the fetal size with birth order ,  [13] , [14] , [15] , [16]  and the higher prevalence of gestational diabetes among the grand multiparae .  [13] , [15] ,

19. Obstetric and Neonatal Outcomes in Grand Multiparity . Obstetrics & Gynecology Grand multiparas were more likely to have had little or no education (none or grade school level), to be smokers , to have an increased body mass index, and to have had poorer prenatal care. Moreover, the rate of women who consumed alcohol during pregnancy was significantly increased in the grand multiparas cohort. They had greater previous histories of fetal or perinatal deaths and had also sought more abortions. The conditional logistic regression model, including grand multiparity, smoking, alcohol habits, chronic hypertension, and chronic diabetes, selected grand multiparity as the parameter the most closely correlated to a previous history of fetal death. CONCLUSION: Grand multiparas, when compared with same-age multiparous controls, appear to have fewer intrapartum complications. However, they present several prenatal risk factors that require special antenatal care.

20. Grand Multiparity : Risk Factors and Outcome in a Tertiary Hospital: a Comparative Study – Buraidah There were significant association between grand multiparity and adverse pregnancy outcomes such as cesarean delivery (OR=2.699, CI=2.072-3.515, p<0.001), fetal macrosomia (OR=1.675; 95% CI=1.004- 2.796, p=.048), Diabetes mellitus (OR=1.634, 95%CI=1.076-2.481, p=0 .021), and pregnancy induced hypertension (OR=1.838, 95% CI=1.054-3.204, p= .032). No significant associations were seen in placenta abruption, placenta previa , preterm labor, postpartum hemorrhage and the frequency of admission to neonatal intensive care unit. No prenatal or maternal mortality was reported in this study. In communities where large family is desirable it is important to address the value of family planning and conduction of meticulous antenatal care. In the current study, we found that there was a significant association between grand multiparity and adverse pregnancy outcomes (such as cesarean delivery, fetal macrosomia, Diabetes mellitus and pregnancy induced hypertension). These findings contradict with previous findings ( 10 , 11 , 12 , 13 ) which concluded that grand multiparity is not associated with increased risk for adverse pregnancy outcomes. Certainly, our data support previous published findings ( 14 , 15 , 16 , 17 ) which stated that grand multiparity continue to constitute potential risks for adverse pregnancy outcomes even after controlling for confounders.

21. Grand multiparity and the possible risk of adverse maternal and neonatal outcomes: a dilemma to be deciphered - KKUH Primiparas responses were more frequent in comparison to multiparas and GMP (56.8% and 33%, and 10.2% respectively). In general, history of miscarriage was elevated (27.2%), and was significantly higher in GMP (58.3%, p  < 0.01). Caesarean delivery was also elevated (19.5%) and was significantly high in the GMP subgroup ( p  < 0.01). However, after adjustment for age, GMP were less likely to deliver by CS (odds ratio: 0.6, 95% CI: 0.4–0.8; p  < 0.01). The two most frequent pregnancy-associated complications were gestational diabetes and spontaneous preterm delivery (12.6% and 9.1%, respectively). The former was significantly more frequent in the GMP ( p  < 0.01). The main neonatal complication was low birth weight (10.7%); nevertheless, neonatal admission to ICU was significantly higher in GMP ( p  = 0.04), and low birth weight was more common in primiparas ( p  < 0.01). Furthermore, logistic regression analysis revealed an insignificant increase in the maternal or neonatal risks in GMP compared to multiparas after adjustment for age. History of miscarriage was significantly higher in GMP group compared to primiparas and multiparas ( p  < 0.01). Most of the pregnancy complications were more frequent in GMP group compared to the other parity sub-groups. GMP women were more likely to have gestational diabetes ( p  < 0.01), gestational hypertension ( p  = 0.01), and ICU admission ( p  = 0.03) The more common adverse effects consistently linked to GMP were gestational diabetes, anemia, placenta previa , malpresentation , low birth weight, and increased perinatal mortality

22. Among young women, grand and great grand multiparity does not increase the risk for most intrapartum and newborn complications. Young grand and great grand multiparas are at significantly decreased risk for many complications when compared with young women of lower parity and older grand and great grand multiparas.

23. Take care p 23 Resources: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610637/ http://www.njcponline.com/article.asp?issn=1119-3077;year=2011;volume=14;issue=1;spage=6;epage=9;aulast=Omole-Ohonsi https://bib.irb.hr/datoteka/442939.grand_multipara_sdarticle_pdf.pdf https://pdfs.semanticscholar.org/608f/56284b5bb8193b80c010dd245b74d7574e39.pdf https://www.qscience.com/docserver/fulltext/qmj/2005/1/qmj.2005.1.12.pdf?expires=1564395517&id=id&accname=guest&checksum=724746BDC494F60420863631CDBCF4AF

24. Thank you

25. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606064/ https://www.ncbi.nlm.nih.gov/pubmed/16135573 https://pdfs.semanticscholar.org/c475/fae8721e3255b6b3372bf1aa78530fd390f8.pdf