**8. Conclusions**

[98, 99], and the presence of coexisting obstetrical or medical complications associated with poorer obstetric outcomes. However, most women over 40 have a successful vaginal delivery even after induction of labour without an increased risk for operative vaginal delivery or

In dichorionic twin pregnancies, the perinatal risks are balanced with the risks associated with iatrogenic prematurity until 37 + 0–6 weeks' gestation and until 36 + 0–6 in monochorionic pregnancies, with higher risks of stillbirths than neonatal deaths beyond this gestation [94]. Pre-labour caesarean delivery may be beneficial in pregnancies with the first twin in noncephalic presentation or when any or both the twins have a low weight, but evidence for both

When obstetric complications such as preeclampsia or diabetes mellitus presented during pergnancy, persistence of medical conditions such as chronic hypertension and type 2 diabetes (T2DM) should be monitored after delivery. Chronic hypertension in women affected by gestational hypertension or preeclampsia is a common event, usually developing years after delivery [101]. Age at pregnancy might reduce this time interval, but this has not been studied before. Likewise, age does not increase the odds of post-partum eclampsia [102]. Age at pregnancy is a risk factor for the development of T2DM when GDM is present [103]. Anyhow, advanced maternal age is a risk factor for developing cardiovascular complications during pregnancy and for developing severe morbidity due to cardiovascular disease [104], so strict

Secondary post-partum haemorrhage is increased in women affected by primary post-partum haemorrhage and in women ≥35 years old, both risk factors being independently associated

Maternal age at delivery >35 years has been indicated as a risk factor for venous thromboembolism in the post-partum period and later in life [106]. However, its contribution is probably

Twin pregnancies are also associated with all the complications mentioned above. Again, this specific population is particularly vulnerable for developing post-partum complications.

Various studies suggest that advanced maternal age at the time of delivery is associated with a higher risk of developing stress urinary incompetence (SUI) in the post-partum period [108, 109]. Suspected aetiological mechanisms are many and they are thought to start developing during pregnancy. Some studies suggest that vaginal delivery may worsen SUI, particularly in elderly women, and advise a caesarean delivery in this population when SUI is already present during pregnancy [108]. However, this protective effect is not consistent in literature, so currently, such a recommendation is controversial [110]. Of course, pelvic floor changes are greater in twin pregnancies, as abdominal pressure on it is irredeemably higher [111]. Anyhow, elderly mothers carrying a twin pregnancy are at higher risk of developing pelvic floor disorders, so preventive strategies should be enforced during pregnancy and early

perineal trauma [100].

110 Multiple Pregnancy - New Challenges

statements is not strong [100].

and long-term follow-up strategies should be put in place.

small when compared to other factors, such as caesarean delivery [107].

investigation and proper treatment in the post-partum period.

**6.2. Post-partum care**

with the event [105].

Twin pregnancy in advanced reproductive age represents a very vulnerable population for obstetric and medical complication during and after pregnancy. Most of these pregnancies are a result of assisted reproduction. Counselling prior to treatment is essential, particularly to discern whether the woman is fit for pregnancy and to enforce specific preventive strategies, such as single embryo transfer. Both conditions, advanced maternal age and twin pregnancy, are risk factors for many obstetric and medical complications. During pregnancy, early diagnosis and treatment of the issues discussed in this chapter can reduce risks and sequelae to the minimum.
