advanced maternal age & pregnancy dr.ashraf fouda ob/gyn. consultant damietta general hospital
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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
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:
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. .
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 MalformationsCongenital Malformations
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 .
Congenital MalformationsCongenital Malformations
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..
HypertensionHypertension
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. .
HypertensionHypertension
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.
Cesarean DeliveryCesarean 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.
Cesarean DeliveryCesarean Delivery
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)
Maternal MortalityMaternal Mortality
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.
Maternal MortalityMaternal Mortality
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) )
Maternal HazardsMaternal Hazards
II) During Labor:II) During Labor:
Dysfunctional labor.Dysfunctional labor.
Prolonged labor.Prolonged labor.
Chorioamnionitis.Chorioamnionitis.
Atonic PPH.Atonic PPH.
Traumatic PPH.Traumatic PPH.
Maternal HazardsMaternal Hazards
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.