advanced maternal age & pregnancy dr.ashraf fouda ob/gyn. consultant damietta general hospital

Advanced Maternal Advanced Maternal Age & PregnancyAge & Pregnancy

Dr .Ashraf Fouda

Ob/Gyn. Consultant

Damietta General Hospital

SourcesSources

Up to date on-line 22/4/2009Up to date on-line 22/4/2009

The older obstetric patient 2008 :The older obstetric patient 2008 :

Mehrnoosh Aref-AdibMehrnoosh Aref-Adib

Theresa Freeman-WangTheresa Freeman-Wang

Ifat AtaullaIfat Ataulla

Advanced Maternal AgeAdvanced Maternal Age

Improvements in women’s Improvements in women’s

general health have led to this general health have led to this

term tending to be reserved term tending to be reserved

for pregnancies in women for pregnancies in women

at or over 40 years of age.at or over 40 years of age.

INTRODUCTIONINTRODUCTION

Fertility clearlyFertility clearly declinesdeclines with advancing age, with advancing age,

especially after the especially after the mid-30smid-30s, and , and

Women who conceive are at Women who conceive are at

greater risk of pregnancy complicationsgreater risk of pregnancy complications

With use of assisted reproductive With use of assisted reproductive

techniques techniques (ART),(ART), births have been births have been

reported in women as old as reported in women as old as 66 years66 years of of

age. age.

The oldest woman to achieve a The oldest woman to achieve a naturallynaturally

conceived pregnancy was conceived pregnancy was 57 years57 years old. old.

INTRODUCTIONINTRODUCTION

Shift towards delayed child Shift towards delayed child bearing is due tobearing is due to::

Changing role of Changing role of women in workwomen in work

{more career opportunities are available}.{more career opportunities are available}.

High female educational level.High female educational level.

↑ ↑ Contraceptive opportunities. Contraceptive opportunities.

↑ ↑ Availability of ART → Availability of ART → Sensation of women Sensation of women

that they may achieve pregnancy and that they may achieve pregnancy and

childbearing at any time.childbearing at any time.

Pregnancy at Advanced Pregnancy at Advanced Maternal Age may be due to:Maternal Age may be due to:

1- Late marriage.1- Late marriage.

2- Long period of primary infertility.2- Long period of primary infertility.

3- Delayed childbearing.3- Delayed childbearing.

Proportion of babies born to mothers of varying age group, showing trend of increased percentage born to mothers in older age groups and fewer in younger mothers.

PREGNANCYPREGNANCY

In the past quarter century, older women in the USA have In the past quarter century, older women in the USA have

accounted for an increasing proportion of total births: accounted for an increasing proportion of total births:

in in 20052005, , 14 %14 % of all births were to women of all births were to women ≥35≥35 years of age . years of age .

For first births, the proportion to women :For first births, the proportion to women :

30-3430-34 years has increasedyears has increased 3-fold3-fold, ,

35-3935-39 years has increasedyears has increased 6-fold6-fold, and , and

≥≥4040 years has increasedyears has increased 15-fold15-fold . .

The The mean age of first-time mothersmean age of first-time mothers

in other in other developed countriesdeveloped countries

is increasing: is increasing:

CanadaCanada (mean age 29.6 years), (mean age 29.6 years),

SwedenSweden (mean age 28.3 years), and (mean age 28.3 years), and

NetherlandsNetherlands (28.7 years). (28.7 years).

PREGNANCYPREGNANCY

EARLY PREGNANCY EARLY PREGNANCY ISSUESISSUES

Older women are at risk for the same Older women are at risk for the same

pregnancy complications as younger pregnancy complications as younger

women, but women, but

their their risk is higherrisk is higher for some of for some of

these problems.these problems.

Spontaneous abortionSpontaneous abortion

Older women experience an increased rate of Older women experience an increased rate of

spontaneous abortion. spontaneous abortion.

These losses are both These losses are both trisomic and euploidtrisomic and euploid

and primarily result from a: and primarily result from a:

decline in oocyte quality; decline in oocyte quality;

changes in uterine and hormonal function. changes in uterine and hormonal function.

The vast majority of losses occur between The vast majority of losses occur between 6 6

and 14 weeks of gestation.and 14 weeks of gestation.

The calculated risk of spontaneous loss in The calculated risk of spontaneous loss in

each age group was :each age group was :

<30<30 years of age years of age (12 %),(12 %),

30 to 3430 to 34 years years (15 %),(15 %),

35 to 3935 to 39 years years (25 %),(25 %),

40 to 4440 to 44 years years (51 %),(51 %),

≥≥4545 years years (93 %).(93 %).

Spontaneous abortionSpontaneous abortion

Down Syndrome Down Syndrome (Trisomy (Trisomy 21)21)

Edward Syndrome (Trisosomy Edward Syndrome (Trisosomy 18)18)

Preconceptional Risks Preconceptional Risks

and Management and Management

↑↑Risk of anueploidy in oocyte:Risk of anueploidy in oocyte:

Definition:Definition:

Abnormal number of chromosomes Abnormal number of chromosomes

around the normal figurearound the normal figure

Causes:Causes: Non-dysjunctionNon-dysjunction

Robertosonian translocationRobertosonian translocation

↑↑Risk of Anueploidy in Oocyte:Risk of Anueploidy in Oocyte:

Types:Types:

A) Monosomy:A) Monosomy:

Absence of one homologous chromosomeAbsence of one homologous chromosome

Autosomal monosomy is fatal.Autosomal monosomy is fatal.

B)B) Trisomy:Trisomy:

presence of 3 homologous chromosome.presence of 3 homologous chromosome.

Management:Management:

ART with preimplantation genetic ART with preimplantation genetic

diagnosis. diagnosis.

+ Transfer only embryos with + Transfer only embryos with

no genetic abnormalities.no genetic abnormalities.

↑↑Risk of Anueploidy in Risk of Anueploidy in Oocyte:Oocyte:

Pre-implantation Pre-implantation genetic diagnosis genetic diagnosis

(PGD)(PGD)

Ectopic pregnancyEctopic pregnancy

Maternal age ≥Maternal age ≥3535 years is associated with a years is associated with a

4-8 4-8 foldfold increased risk of ectopic increased risk of ectopic

pregnancy compared with younger women. pregnancy compared with younger women.

This high risk likely reflects an accumulation of risk This high risk likely reflects an accumulation of risk

factors over time, such as: factors over time, such as:

Multiple sexual partners, Multiple sexual partners,

Pelvic infection, and Pelvic infection, and

Tubal pathologyTubal pathology. .

Congenital MalformationsCongenital Malformations

The risk of having a child with a congenital The risk of having a child with a congenital

anomaly anomaly may increasemay increase with increasing with increasing

maternal age. maternal age.

This is attributed to the recognized This is attributed to the recognized increase of increase of

aneuploidyaneuploidy with advancing maternal age and with advancing maternal age and

the association of aneuploid fetuses with the association of aneuploid fetuses with

structural anomaliesstructural anomalies. .

Increased Risk for Down Increased Risk for Down SyndromeSyndrome

More recent analysis suggests that, as More recent analysis suggests that, as

women age, the risk of women age, the risk of non-chromosomal non-chromosomal

anomalies increasesanomalies increases. .

Cardiac anomaliesCardiac anomalies, in particular, seem to , in particular, seem to

increase with maternal age independent of increase with maternal age independent of

aneuploidy.aneuploidy.

Clubfoot and congenital diaphragmatic Clubfoot and congenital diaphragmatic

herniahernia were also increased. were also increased.


Congenital malformation rate:Congenital malformation rate:

3.5%,3.5%, in women in women 20-24 years20-24 years of age of age

4.4%4.4% in women in women 35 to 3935 to 39 years and years and

5% 5% in women ≥in women ≥40 40 years .years .


LATE PREGNANCY ISSUESLATE PREGNANCY ISSUES

Some obstetrical complications appear to be Some obstetrical complications appear to be

related to the related to the aging process aloneaging process alone, ,

While others are largely related to While others are largely related to coexisting coexisting

factorsfactors such as: such as:

multiple gestation, higher parity, and chronic multiple gestation, higher parity, and chronic

medical conditionsmedical conditions, ,

which are less likely to be observed in younger which are less likely to be observed in younger

women. women.

Effects of Coexisting Medical Effects of Coexisting Medical ConditionsConditions

The prevalence of The prevalence of medical and surgical medical and surgical

illnessesillnesses, such as: , such as:

cancer and cardiovascular, renal, and cancer and cardiovascular, renal, and

autoimmune diseaseautoimmune disease, increases with advancing , increases with advancing

age. age.

So, women ≥35 years of age can expect to So, women ≥35 years of age can expect to

experience experience 2-32-3 fold higher ratesfold higher rates of of

hospitalization, cesarean delivery, and pregnancy-hospitalization, cesarean delivery, and pregnancy-

related complicationsrelated complications

than their younger counterparts. than their younger counterparts.

SmokingSmoking has been associated with has been associated with

increased increased perinatal morbidity and perinatal morbidity and

stillbirthstillbirth in all age groups, but the risk is in all age groups, but the risk is

particularly particularly high in older smokershigh in older smokers. .

SmokingSmoking

The The two most common medical two most common medical

problemsproblems complicating pregnancy are complicating pregnancy are

hypertensionhypertension

(preexisting and pregnancy related) (preexisting and pregnancy related)

and and

diabetesdiabetes

(pregestational and gestational).(pregestational and gestational).

Effects of Coexisting Medical Effects of Coexisting Medical ConditionsConditions

HypertensionHypertension

HypertensionHypertension is the most common is the most common

medical problem encountered in medical problem encountered in

pregnancy and is particularly prevalent in pregnancy and is particularly prevalent in

older women. older women.

Chronic hypertension is Chronic hypertension is 2-4 fold2-4 fold higher higher

in women in women ≥35 years≥35 years of age than in of age than in

women women 30 - 34 years30 - 34 years of age. of age.

The incidence of preeclampsia in the The incidence of preeclampsia in the

general obstetric population is general obstetric population is 3 - 4%3 - 4%

Increases toIncreases to::

5 - 10%5 - 10% in women in women over age 40over age 40 and is as and is as

high ashigh as

35 %35 % in women in women over age 50over age 50..


Maternal and fetal morbidity and mortalityMaternal and fetal morbidity and mortality

related to hypertensive disorders during related to hypertensive disorders during

pregnancy can be reduced with: pregnancy can be reduced with:

Careful monitoring and Careful monitoring and

Appropriately timed intervention,Appropriately timed intervention,

But with an increase inBut with an increase in : :

Preterm birth, Preterm birth,

IUGR, and IUGR, and

Cesarean deliveryCesarean delivery. .


Diabetes mellitusDiabetes mellitus

The prevalence of diabetes increases with The prevalence of diabetes increases with

maternal age. maternal age.

The rates of both The rates of both preexisting diabetes mellitus preexisting diabetes mellitus

and gestational diabetesand gestational diabetes increase increase 3-3-

6 fold6 fold in women in women ≥≥40 40 years,years,

compared with women aged compared with women aged 20 - 29 20 - 29 years .years .

The incidence in the general obstetric The incidence in the general obstetric

population of population of gestational diabetesgestational diabetes is is 3%3%

rising to: rising to:

7 to 12%7 to 12% in women in women over age 40over age 40, and , and

20%20% in women in women over age 50over age 50..

Diabetes MellitusDiabetes Mellitus

Preexisting diabetesPreexisting diabetes is associated with is associated with

increased risks of: increased risks of:

congenital anomalies, perinatal congenital anomalies, perinatal

mortality, and perinatal morbiditymortality, and perinatal morbidity, ,

While the major complication of While the major complication of gestational gestational

diabetesdiabetes is is macrosomiamacrosomia and its sequelae. and its sequelae.

Diabetes MellitusDiabetes Mellitus

Placental ProblemsPlacental Problems

The prevalence of placental problems, such as: The prevalence of placental problems, such as:

abruptio abruptio

placenta and placenta previaplacenta and placenta previa, ,

is higher among is higher among

older women.older women.

MultiparityMultiparity accounts for significant proportion accounts for significant proportion

of the excess risk in both disorders. of the excess risk in both disorders.

Perinatal MorbidityPerinatal Morbidity

Advanced maternal age is responsible for Advanced maternal age is responsible for

a substantial proportion of the a substantial proportion of the

increased rate of:increased rate of:

low birth weight (LBW)low birth weight (LBW) and and

preterm delivery (PTD)preterm delivery (PTD). .

Perinatal MortalityPerinatal Mortality

The relative risk of stillbirth increases The relative risk of stillbirth increases

with increasing maternal age with increasing maternal age

(ie, it is higher at age 40 than at age 35)(ie, it is higher at age 40 than at age 35)

and is most notable after and is most notable after

about 37 weeks of gestation .about 37 weeks of gestation .

The excess perinatal mortality is largely The excess perinatal mortality is largely

due to due to non-anomalous fetal deathsnon-anomalous fetal deaths, ,

which are which are often unexplainedoften unexplained, even , even

after controlling for risk factors such as: after controlling for risk factors such as:

hypertension, diabetes, antepartum hypertension, diabetes, antepartum

bleeding, smokingbleeding, smoking. .

Perinatal MortalityPerinatal Mortality

Multiple GestationMultiple Gestation

Advancing age is associated with an Advancing age is associated with an

increased prevalence of twin pregnancy,increased prevalence of twin pregnancy,

It is related to both a It is related to both a

higher risk of naturally-conceived twinshigher risk of naturally-conceived twins

and a and a higher use of ART in older womenhigher use of ART in older women. .

Interestingly, in contrast to singletons, Interestingly, in contrast to singletons,

the the outcomeoutcome

of multiple pregnancies in older of multiple pregnancies in older

women is women is as good or betteras good or better than the than the

outcome in younger women .outcome in younger women .

Multiple GestationMultiple Gestation

Older women are more likely Older women are more likely to to

be delivered by cesarean be delivered by cesarean than younger women than younger women

The cesarean delivery rate in women: The cesarean delivery rate in women:

50%50% at ageat age 40 - 4540 - 45 and and

80 -100%80 -100% at age overat age over 50 50 years, years,

The rate in the general obstetric population of the The rate in the general obstetric population of the

United States was aboutUnited States was about 25%.25%.

Cesarean DeliveryCesarean Delivery

The reasons for the high rate of operative delivery in The reasons for the high rate of operative delivery in

older women include an:older women include an:

Increased prevalence of Increased prevalence of medical complicationsmedical complications, ,

Induction of laborInduction of labor, and , and

Fetal malpositionFetal malposition, as well as a , as well as a

Lower thresholdLower threshold among both patients and physicians among both patients and physicians

for performing a cesarean delivery. for performing a cesarean delivery.


Maternal requestMaternal request ( (cesarean on demandcesarean on demand) )

is becoming more common, particularly among is becoming more common, particularly among

older gravidae. older gravidae.

Older women appear to have an Older women appear to have an increased risk increased risk

of cephalopelvic disproportionof cephalopelvic disproportion resulting in resulting in

failure of labor to progress normally. failure of labor to progress normally.


The linear increase in the relationship between The linear increase in the relationship between

maternal age and uterine dysfunction is a maternal age and uterine dysfunction is a

continuous effectcontinuous effect throughout the childbearing throughout the childbearing

years.years.

Older women who undergo a trial of labor after Older women who undergo a trial of labor after

a previous cesarean are at a previous cesarean are at increased risk of increased risk of

both both failed trial of laborfailed trial of labor andand uterine ruptureuterine rupture. .

Dysfunctional LaborDysfunctional Labor

Maternal MortalityMaternal Mortality

Older women are at increased risk of Older women are at increased risk of

maternal death, maternal death,

Only a small effect in Only a small effect in developed developed

countriescountries since the risk of dying during since the risk of dying during

childbirth is already very low in these childbirth is already very low in these

areas. areas.

In the In the United States from 1991 to 1997United States from 1991 to 1997, the , the

risk maternal mortality for women:risk maternal mortality for women:

35 - 3935 - 39 years of age was years of age was more than twicemore than twice

that of women aged that of women aged 25 - 29 years25 - 29 years

(21 per 100,000 live births); (21 per 100,000 live births);

Over 40 yearsOver 40 years old, was old, was 5 -5 - fold higherfold higher

(46 per 100,000 live births)(46 per 100,000 live births)


In developing nationsIn developing nations, however, , however,

maternal mortality remains a significant maternal mortality remains a significant

problem. problem.

Lack of adequate careLack of adequate care

contributes to these maternal losses, but contributes to these maternal losses, but

increasing age and parityincreasing age and parity are also are also

significant contributors.significant contributors.


Fetal HazardsFetal Hazards

1- Higher incidence of:1- Higher incidence of: Chromosomal abnormalities. Chromosomal abnormalities.

(triosmy 21 → 1/350 after age of 35 yrs) .(triosmy 21 → 1/350 after age of 35 yrs) . Congenital fetal malformation.Congenital fetal malformation. Spontaneous abortion.Spontaneous abortion. IUGR. IUGR. Preterm labor with all the hazards of Preterm labor with all the hazards of

prematurity.prematurity.

2- 2- ↑ ↑ Perinatal mortality ratePerinatal mortality rate

Maternal HazardsMaternal Hazards

I) During pregnancy:I) During pregnancy:

1- Higher incidence of1- Higher incidence of

PIHPIH {Preeclampsia & eclampsia} {Preeclampsia & eclampsia}

Spontaneous abortionSpontaneous abortion and its complications. and its complications.

Ectopic pregnancy & Vesicular moleEctopic pregnancy & Vesicular mole

2-Diabetes and its complications2-Diabetes and its complications

( (after age of 40yrsafter age of 40yrs))

3-Abnormal placentaion3-Abnormal placentaion

( (placental abruption, & placenta previaplacental abruption, & placenta previa) )


II) During Labor:II) During Labor:

Dysfunctional labor.Dysfunctional labor.

Prolonged labor.Prolonged labor.

Chorioamnionitis.Chorioamnionitis.

Atonic PPH.Atonic PPH.

Traumatic PPH.Traumatic PPH.


III) During Puerperium:III) During Puerperium:

Subinvolution of the uterus.Subinvolution of the uterus.

Purperal sepsis.Purperal sepsis.

N.B: N.B: Important Note:Important Note:

Delayed childbearingDelayed childbearing : :→ → eliminate the eliminate the

protective effect of pregnancy against protective effect of pregnancy against

cancer ovary & cancer breast.cancer ovary & cancer breast.

Pregnancy complications that occur with increased Pregnancy complications that occur with increased

frequency in older gravidae include: frequency in older gravidae include:

Ectopic pregnancy, Ectopic pregnancy,

Spontaneous abortion, Spontaneous abortion,

Fetal chromosomal abnormalities, Fetal chromosomal abnormalities,

Some congenital anomalies, Some congenital anomalies,

Placental problems, Placental problems,

Gestational diabetes, Gestational diabetes,

Pre-eclampsia, and Pre-eclampsia, and

Cesarean delivery. Cesarean delivery.

Women should be advised about the risks of

Down syndrome and other aneuploidies.

They should be made aware of:

Available screening techniques,

Their accuracy and effectiveness, as well as the

Inherent risks of definitive testing with

amniocentesis or chorionic villus sampling

Pre-pregnancy Counseling

Antenatal Care

Reassurance and psychological support

Pre-existing medical conditions must be

taken into account, especially the risks of

hypertension, diabetes and cardiovascular

problems, which need a multidisciplinary

approach to management.

Intrapartum and Delivery

Health Careers should be aware of

the increased frequency of severe

complications

that may threaten the health and

life of the older obstetric patient

Despite the apparent risks of pregnancy, labour Despite the apparent risks of pregnancy, labour

and delivery associated with increasing maternal and delivery associated with increasing maternal

age, age,

It is important to know that the majority of women It is important to know that the majority of women

in this category have in this category have

successful pregnancies and healthy childrensuccessful pregnancies and healthy children, ,

and the risks are very small in absolute numbers. and the risks are very small in absolute numbers.

Good antenatal care, with appropriate and Good antenatal care, with appropriate and

accurate informationaccurate information, can have a positive , can have a positive

influence on the overall outcome.influence on the overall outcome.

The other face of the coinThe other face of the coin

There can be advantages to delaying

childbearing.

The older age groups are often:

Better educated,

Financially more secure and, possibly,

Emotionally better prepared for pregnancy.

The End!The End!

advanced maternal age & pregnancy dr.ashraf fouda ob/gyn. consultant damietta general hospital

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