PREGNANCY IN THE OLDER WOMAN Evan O Nepaul MBBS, DM, FACOG

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PREGNANCY IN THE OLDER WOMAN

• Evan O Nepaul MBBS, DM, FACOG, FRCOG
• Consultant Obstetrician Gynaecologist

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• Incidence
• Maternal Complications
• Fetal and Neonatal Complications
• Management
• Socio-Economic Considerations

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• 1959 FIGO Elderly Primgravida Women in their
  first pregnancy above the age of 35.
• An indelicate term which has become outmoded.
• Product of the baby boom- world war 11
• Women are more well-educated
• Advance and successful infertility management

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England and Wales

• Births to Women over 30 years 1986 28
• Births to Women over 30 years 2006 48
• Births to women over 40 years 1986 1.1
• Births to women over 40 years 2006 3.5
• Over 40 yrs more than double over the last two
  decades

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INCIDENCESPGH Savannalamar Public General
Hospital 5 year review
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What effect does age have on fertility?

• Being 35 or over does raise certain important
  issues for women and men choosing to wait to
  start a family.
• There is a gradual decrease in fertility
• Sub-fertility or Infertility. It is estimated
  that about 20 per cent of women aged 35 to 39 are
  infertile.

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Maternal Age and Multiple Pregnancy

• Waterhouse (1950) Positive effects of increasing
  maternal age and parity on the incidence of
  twinning.
• Twin pregnancies were less than one third as
  common in women under 20 with no previous
  children than in women 35 to 40 with 4 or more
  previous children.

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MATERNAL COMPLICATIONS

• Medical Complications
• Late Pregnancy Bleeding
• Caesarean Section
• Maternal Mortality

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Medical Complications

• Diabetes and Hypertension increased in frequency.
• Type 11 Diabetes increases with frequency with
  age.
• Gestational Diabetes increases with increasing
  age.
• Diabetes in some form is increased 2 -3 times
  than in those who are 20 to 25 yrs.

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SPGH Diabetes in Pregnancy
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SPGH Hypertensive Disorders
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Other Medical and Surgical Conditions

• Cardiovascular
• Neurological
• Connective Tissue Disorders
• Renal Disorders
• Pulmonary Disorders
• Cancers
• Alcoholism
• thus, antepartum hospital admissions are
  substantially more frequent among older than
  among younger women

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Medical Risk in the Postpartum

• Thrombotic complications.
• Pulmonary oedema.
• Higher incidence of Heart Failure is often
  related to chronic underlying hypertension.

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Late Pregnancy Bleeding

• Incidence of Placental Abruption and Placenta
  Previa increase in older women.
• Increase incidence of chronic hypertension
  thought to contribute to the higher incidence of
  abruptio.

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Caesarean Section

• Caesrean section rate increase substantially.
  Risk actually doubled.
• Multi-factorial, increased in hypertensive
  disorders, diabetes, preterm labour, and abruptio
• Prolonged labour more common, especially in
  nulliparous.
• Patient and Physician concern for pregnancy
  outcome.

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SPGH Normal Delivery vs C-Section
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Maternal Mortality

• Mortality rate for women age 3539 yrs were
  increased fourfold compared with 20-24 yrs.
• Discrepancy was more marked in non-whites.
• The increased risk appears to be principally due
  to a more frequent association of pregnancy and
  preexisting medical condition in older women.
• Those without such underlying problems do not
  have increased risk.
• Incidence of ectopic pregnancy is increased with
  maternal age.

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FETAL and NEONATAL COMPLICATIONS

• Abortion
• Preterm Delivery and Restricted Fetal Growth
• Macrosomia
• Congenital Malformations
• Perinatal Mortality
• Infant Mortality

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Abortion

• Increased in spontaneous abortion with increased
  in age 4-fold increased in the 40 yr compared to
  the 20 yr.
• Increased risk of abnormal fetal karyotype most
  first trimester and 30 of 2nd trimester losses
  are associated with chromosomal abnormalies.
• Effects of preexisting medical conditions.

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Molar Pregnancy

• Relatively higher frequency among pregnancies
  toward the extremes of childbearing period
• Pronounce effect is seen in women over 45
  relative frequency is 10 times greater than at
  ages 20 to 40.

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Preterm Delivery and Restricted Fetal Growth

• The incidence of low birth weight infants is
  increased because of
• spontaneous
• induced preterm delivery
• fetal growth restriction.
• Hansen (1986), Prysak and co-worker ( 1995)

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Macrosomia

• Older woman have a higher incidence of macrosomic
  babies.
• However the observed statistical risk is of
  insufficient magnitude alone to affect the
  decision for c-section in older women to avoid
  shoulder dystocia.

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Congenital Malformations

• It is well-known that older women have a higher
  chance of having a baby with a genetic
  abnormality, such as Downs syndrome, Edward's
  syndrome or Patau's syndrome.
• Excluding Down syndrome, there was only a slight
  maternal age effect on other malformations after
  age 40.
• There is another small but serious risk to the
  babies of more mature mothers. More babies die in
  the uterus right at the end of pregnancy in
  mothers aged over 40.
• Figures for 2006 show that the rates of
  stillbirth were steady at around 5 to 6 babies
  per 1,000 births for women aged 20 to 39, but
  increased to just under 9 babies per 1,000 births
  for women aged 40 and over.

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• This increased risk cannot be explained by
  complications in the pregnancy or other illnesses
  alone. For this reason care-givers are often more
  vigilant of older mothers in the final weeks of
  pregnancy.
• Despite the increased risk with increased age, it
  is important to remember that the vast majority
  of babies are fine. Except for the factor of
  chromosomal abnormalities, figures suggest that
  babies of older mothers are no more at risk of
  most birth defects than those of younger mothers.
  

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Perinatal Mortality and Infant Mortality

• Perinatal mortality is increased substantially
  and stillbirths principally account for the
  increase.
• Although the risk of infant mortality was almost
  identical for women aged 25 to 29 compared to 30
  to 34, mother aged 35 to 39 yrs had an 18
  increased mortality risk while those born to
  mothers age 40-49 yrs had a 69 increased risk.

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MANAGEMENT

• Prenatal Counseling diet, folic acid, meticulous
  control of medical disorders with appropriate
  medications that are not teratogenic.
• Early antenatal booking
• Thorough Medical and Ob/Gyn History
• Ascertain gestational age
• Wt BP

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• Thorough head-to-toe examination
• Detailed gyne examination
• Urinalysis CBC Sickle test 1-hr GTT (Hb A1c)
  UE Gp Rh Syphilis and HIV screening
• Ultrasound Scan. First or early second trimester,
  and detailed anomaly scan at 18-22 wks.
• Triple or Quad test
• Amniocentesis / Chorionic villous biopsy

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Triple and Quad Screening

• alpha-fetoprotein (AFP), a protein produced by
  the baby's liver
• human chorionic gonadotropin (hCG), a hormone
  produced by the placenta
• estriol (uE3), a hormone produced in the placenta
  and the liver of the baby
• dimeric inhibin-A (DIA), a protein made by the
  placenta.
• test is done between the 15th and 18th weeks of
  pregnancy.

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Birth Defects These Tests May Detect

• Down syndrome or other chromosome problems
• Neural tube defects
• GI abnormalities
• Renal abnormalities
• severe skin disorders
• These blood screening tests detect
• 95 of cases of anencephaly
• 80 of serious cases of spina bifida
• 60 or more of the cases of Down syndrome.

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• Monthly visits or as other conditions necessitate
• Fortnightly visits after 28 weeks
• Glucose tolerance test at 24-28 wks
• Weekly visits after 36 weeks
• Fetal Surveillance weekly after 36 weeks DFMC
  Biophysical Profile Uterine Artery Doppler
• Individualization of care
• Mode of delivery

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Share - Care
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Contraceptives
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Socio-Economic Considerations

• Complexity of care
• Increase need for high-technology prenatal care
• Genetic counseling and prenatal diagnosis
• Amniocentesis
• Ultrasound examination
• Test for fetal well-being
• Twofold increased incidence of long-term
  antenatal hospitalization

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SUMMARY

• Pregnancy in the older woman is associated with a
  number of complications due to underlying chronic
  disorders that inevitably go along with aging.
• Fortunately these disorders are identifiable and
  can be treated successfully.
• Women should realistically appraise the risks,
  but should not necessarily fear delaying
  childbirth.
• Pregnancy in the older woman is increasingly
  common in our society, and improved maternal care
  has made advance maternal age compatible with
  successful pregnancy for the great majority of
  such woman.

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ADRIANA ILIESCU, the 66-year-old
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THANK YOU!!