**6. Delivery and post-partum care in twin pregnancies in advanced maternal age**

#### **6.1. Delivery mode and time of delivery**

Advanced maternal age is associated with a high frequency of caesarean delivery. Many factors participate in this. For instances, a more frequent prolonged labour due to worse myometrial function and decreased flexibility of pelvic joints [97], increased frequency of large babies [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 perineal trauma [100].

Advanced maternal age is considered to be a risk factor for post-partum depression [112]. This is a poorly studied condition, which can be devastating for the mothers, children, and family. On the other hand, parents of twins frequently experience higher levels of anxiety and depression and are at higher risk for post-partum depression and for marital decline [113, 114]. Post-partum depression has also been linked to preterm birth, so common among twins, due to a lesser mother-infant interaction and parents' concern for both medical and economic subsequent issues [115]. Sleeping disorders 3 months post-partum are more frequent in mothers

Multiple Pregnancy in Women of Advanced Reproductive Age

http://dx.doi.org/10.5772/intechopen.81096

111

Several neurological disorders have been shown to be more frequent in children born from elderly mothers, particularly cerebral palsy [117, 118] and autism spectrum disorders [119]. In terms of learning disabilities, one study found that developmental vulnerability decreases with the mother's age from 15 to 30 years, but starts to increase when the mother is older than 35, this increase being independent from the socioeconomic status [120]. Interestingly, children born from old parents show a poorer neurocognitive performance in childhood [121]. However, environment might make up for the "biological disadvantage", as older parents are usually in a better financial state, are more highly educated, and usually have reached a more stable couple/marriage situation. All this may give them certain emotional maturity and life experience that improves child-rearing abilities. Compared to singletons, twins exhibited higher rates of cerebral palsy and mental retardation and showed more pronounced speech delays, motor development, and behavioural problems. However, the main explaining factor is the higher frequency for preterm delivery that results in low and very low birth weight children [122]. Maternal age contributes by increasing the risk for preterm delivery, but the

Trisomy 21 is very well known to increase with maternal age due to meiotic non-disjunction errors. More recently, mitochondrial dysfunction and epigenetic changes associated with oocyte ageing can be inherited by the descendant and may predispose also to chromosome

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

older than 35 years old [116]. Psychosocial and physical support should be provided.

**7. Long-term disabilities due to advanced maternal age**

same way in singletons and twins.

**8. Conclusions**

to the minimum.

segregation errors in grandchildren [123].

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 statements is not strong [100].
