Risks and Complications of Pregnancy with Increasing Age

1. Risks and Complications of Pregnancy with Increasing Age Katie Spencer Advisor: D. French

2. Overview • Do mothers of advancing age (≥ 35) have increased risks associated with pregnancy? • What risks do they have? • How do we educate our patients to minimize these risks?

3. Do women of advancing age have increased risks in pregnancy? • All pregnancies carry some form of risk to the mother and baby. • Some of these risks increase as the age of the mother increases. • Women 35 and over have more risks associated with pregnancy than younger women. • Older women may have more comorbid conditions that contribute to pregnancy risks.

4. What are some of these increasing risks? • Abruptio placentae - the implanted placenta prematurely separates from the uterine wall. Associated with hypertension, trauma, increased amounts of amniotic fluid, multiples, and cocaine use. • Placenta previa - placenta is positioned close to or over the internal cervical os. Abnormal vascularization is thought to play a part. Associated with previous C-section, increased maternal age, and increased number of previous pregnancies.

5. What are some of these increasing risks? • Preeclampsia – mother develops sustained HTN (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg) with proteinuria brought on by pregnancy, usually in the second half of gestation. It can affect many of the mother’s body systems, and can cause problems with the fetus by decreasing placental perfusion. Associated with previous miscarriage and the extremes of reproductive age.

6. What are some of these increasing risks? • Eclampsia – usually occurs in a woman who has preeclampsia. The defining characteristic is convulsions not caused by a neurological disorder. Most cases occur within 24 hrs of delivery, but can happen up to 10 days after birth. Can cause maternal death. • Chronic hypertension – mother has HTN before the 20th week of gestation, or beyond 6 weeks after delivery. Usually caused by essential HTN, the risk for which increases with age. Increases risk of developing preeclampsia and eclampsia.

7. What are some of these increasing risks? • Diabetes – type I, type II, or gestational diabetes can occur in pregnancy. Diabetes in pregnancy can lead to preeclampsia. It can also cause ketoacidosis and retinopathy in the mother. It can lead to congenital anomalies, IUGR, macrosomia (> 4000 g) which can cause problems in delivery, and can lead to a hypoglycemic neonate. Uncontrolled diabetes during pregnancy increases the risk of spontaneous abortion (< 20 wks) and stillbirth (≥ 20 wks). Type II diabetes may be a comorbidity in a mother of advancing age.

8. What are some of these increasing risks? • Chromosomal abnormalities - may be due to the deteriorating quality of the ova with advancing age (Heffner, 2004). Types of abnormalities: • Down syndrome (trisomy 21) • Edwards syndrome (trisomy 18) • Kleinfelter syndrome (sex chromosome polysomy) • many others Each of these chromosomal abnormalities causes different characteristic changes of the fetus, various mental changes, and altered life expectancies of the neonate. The incidence of Down syndrome among all newborns is about 1:800. For mothers age 35, the incidence is 1:385, and for mothers age 45, the incidence is 1:33 (Beckmann et al., 2006). Men with advancing paternal age also have an increased risk of producing a child with an autosomal dominant disease, like Marfan syndrome, because of increased genetic mutations (Heffner, 2004).

9. What are some of these increasing risks? • Infertility – can be caused by maternal issues associated with age such as premature ovarian failure, perimenopause, and menopause. Can also be due to anovulation, anatomical defects, or a variety of other problems in the female. May also be due to abnormal spermatogenesis in the male.

10. How can you counsel your patients? Preconception: • Healthy diet- prenatal vitamins and folic acid • Moderate exercise Women who have a BMI over 29 have increased risks, regardless of age, including preeclampsia, thromboembolism, C-section, wound infection, and anesthesia complications (Montan, 2007). • Refraining from drinking, smoking, and drugs • Counsel mother on obtaining prenatal care

11. How can you counsel your patients? • Comorbidities – educate pts on lifestyle modifications. Urge them to get their conditions under control before becoming pregnant. • Medications – educate pts about their medications (Rx, OTC, and supplements). Determine pregnancy categories and risk vs benefit. Decide if certain meds need to be changed or stopped.

12. How can you counsel your patients? • Genetic counseling – The goal is to collect information from your patient to assess the risk of the mother developing disease or conceiving an infant with congenital abnormalities, to inform your patient of screening and diagnostic tests that are available to them, and also to discuss alternative reproductive options, if necessary. Use easily understood language, and answer all questions to the patient’s satisfaction. The counseling should be informative and supportive to the patient, but free of personal opinion. (Beckmann et al., 2006).

13. How can you counsel and manage your patients? During Pregnancy • Encourage mother to get good prenatal care • Screen for diabetes • Screen for hypertension • Do Maternal serum alpha fetoprotein (MSAFP) to screen for neural tube defects

14. How can you counsel and manage your patients? • Mothers who are at higher risk of having a child with congenital abnormalities, based on their genetic counseling, may consider screening tests or fetal chromosome analysis early in pregnancy. • Amniocentesis – done at 15-20 wks gestation, needle guided by ultrasound removes 20-40 mL of amniotic fluid. Cells in the fluid are cultured and examined. Neural tube defects can also be detected by examining the fluid.

15. How can you counsel and manage your patients? • Chorionic Villus Sampling – 10-12 wks, immature placental tissue is aspirated guided by ultrasound. The cells can be examined for chromosomal abnormalities. Neural tube defects cannot be detected. • Other tests that are more invasive, such as fetal skin sampling, fetal tissue biopsy, and fetoscopy can be used for diagnosis of rare disorders that cannot be diagnosed by other tests.

16. How can you counsel your patients? Labor and Delivery • Decreased placental function can lead to low birth weight (<2,500 g) neonates. • IUGR can also lead to low birth weights or preterm births. • Increasing age is related to preterm birth (<37 wks). • Mothers of advancing age are more likely to deliver by C-section. This may be due to the care providers having a lower threshold of intervention with mothers of advancing age, the increased likelihood of breech presentation, or that older mothers are more likely to have post partum hemorrhage if they deliver vaginally (Jolly et al., 2000).

17. How can you counsel your patients? Post-partum • The mother of advancing age may have a longer recovery time from vaginal or caesarean birth, as her body needs extra time to heal damaged tissues. She may need extra time in the hospital or at home to recover before returning to usual activities. • Mothers should be given information on proper development of the baby, breastfeeding, bonding with the baby, and her health. She should also be given resources about nutrition, exercise, handling stress, and depression.

18. How can you counsel your patients? • If the newborn does have chromosomal or congenital abnormalities, the family needs to be counseled on the course of the condition and what to expect. They should also be given resources for finding information and support groups, and dealing with the stress of this event. • Any complications that occur with pregnancy may require professional counseling for the patient, as well as empathy from the health care provider.

19. Conclusions Mothers of advancing age may have a number of increased risks surrounding pregnancy to consider before conception and during pregnancy. The risks in each stage of the process are increased in comparison to their younger counterparts.

20. Conclusions It is certainly possible for these women to conceive, have healthy pregnancies, and to bear healthy babies. Advancing age is not a reason to abstain from becoming pregnant, but it does carry increased risks that should be discussed and watched for by the practitioner and the patient.

21. References • Beckmann CRB, Ling FW, Smith RP, Barzansky BM, Herbert WNP, Laube DW. Obstetrics and Gynecology. 5th ed. Philadelphia: Lippincott Williams &Wilkins; 2006. • de la Rochebrochard E and Thonneau P. Paternal age and maternal age are risk factors for miscarriage; results of a multicenter European study. Hum Reprod. 2002 Jun;17:1649–1656. • Hackmon R, James R, O’Reilly Green C, Ferber A, Barnhard Y, Divon M. The impact of maternal age, body mass index and maternal weight gain on the glucose challenge test in pregnancy. J Matern Fetal Neonatal Med. 2007 Mar;20(3):253-7. • Heffner LJ. Maternal age – how old is too old? N Engl J Med. 2004 Nov 4; 351(19):1927-1929. • Jacobson B, Ladfors L, Milsom I. Advanced maternal age and adverse perinatal outcome. Obstet Gynecol. 2004;104:727-733. • Jolly M, Sebire N, Harris J, Robinson S, Regan L. The risks associated with pregnancy in women aged 35 and older. Hum Reprod. 2000 Nov;15(11):2433-2437. • Luke B, Brown MB. Elevated risks of pregnancy complications and adverse outcomes with increasing maternal age. Hum Reprod. 2007 May;22(5):1264-72. • Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, and Munson SL. Births: final data for 2004. National Vital Statistics Reports. 2006; 55(1). National Center for Health Statistics, Hyattsville, MD. • Montan S. Increased risk in the elderly parturient. Curr Opin Obstet Gynecol. 2007 Apr; 19(2):110-112. • Nabukera S, Wingate MS, Alexander GR, Salihu HM. First-time births among women 30 years and older in the United States: patterns and risk of adverse outcomes. J Reprod Med. 2006 Sep; 51(9):676-682.

22. References • Neumann M, Graf C. Pregnancy after 35. Are these women at high risk? AWHONN Lifelines. 2003 Oct-Nov; 7(5):422-430. • Odibo A, Nelson D, Stamilio D, Sehdev H, Macones G. Advanced maternal age is an independent risk factor for intrauterine growth restriction. Amer J Perinatol. 2006 Jul;23(5):325-328. • Ozalp S, Tanir HM, Sener T, Yazan S, Keskin AE. Health risks for early (< or =19) and late (> or =35) childbearing. Arch Gynecol Obstet. 2003 Aug;268(3):172-174. • Salihu HM, Shumpert N, Slay M, Kirby R, Alexander G. Childbearing beyond maternal age 50 and fetal outcomes in the United States. Obstet Gynecol. 2003;102:1006-1014. • Simchen MJ, Yinon Y, Moran O, Schiff E, Sivan, E. Pregnancy outcome after age 50. • Obstet Gynecol.2006;108:1084-1088. • Snijders RJ, Sundberg K, Holzgreve W, Henry G, Nicolaides KH. Maternal age- and gestation-specific risk for trisomy 21. Ultrasound Obstet Gynecol. 1999 Mar;13(3):167-170. • Vergani P, Locatelli A, Biffi A, Zagarella A, Pezzullo JC, Ghidini A. Factors affecting the decision regarding amniocentesis in women at genetic risk because of age 35 years or older. Prenat Diagn. 2002 Sep; 22(9):769-774.