Pinky Ronen, M.D.
Advance maternal age, a poorly worded term, refers to women who defer child bearing plans beyond the age of 35 at the time of delivery. Women who delay childbearing are at increased risk of infertility and certain pregnancy complications. Providing information to all patients of child-bearing age about the obstetrical risks of advanced maternal age can help them make informed decisions about the timing of child-bearing.
Women should know that the probability of achieving a pregnancy begins to decline significantly at about age 32 and that coexisting medical disease and pregnancy complications become more common with advancing age. These complications include ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, some congenital anomalies, placenta previa, gestational diabetes, preeclampsia, and cesarean delivery. Such complications may, in turn, result in preterm birth. There is also an increased risk of perinatal mortality.
FERTILITY — This term refers to the ability of a couple to conceive.
Many experts suggest initiating a fertility evaluation after six months of unprotected intercourse without conception in women 35 to 40 years of age, and immediate evaluation in women over 40 years of age
The late reproductive stage is characterized by a transition from fertility, to subfertility, and finally sterility. Sterility due to age-related ovarian insufficiency can be difficult to diagnose in the absence of 12 months of amenorrhea because ovarian function oscillates during the late reproductive stage and the menopausal transition. FSH levels are not useful for predicting an older woman’s inability to conceive. However, a woman who has FSH levels >50 pg/mL on three occasions over six months with estradiol levels <20 pg/mL is highly likely to be sterile because of complete or near complete depletion of the ovarian follicle pool.
Expectant management of age-related infertility is an option for couples who do not desire medical intervention. Options for active intervention include controlled ovarian stimulation with intrauterine insemination (IUI), in vitro fertilization (IVF), and oocyte donation.
Controlled ovarian stimulation and intrauterine insemination — The negative effect of older age on success of controlled ovarian stimulation and IUI was illustrated in different studies.
The following suggestions apply to women ≥35 years of age at the estimated date of delivery:
The risk of fetal chromosomal abnormalities based on maternal age should be reviewed. There are two approaches to identifying fetal aneuploidy: (1) invasive testing (amniocentesis, chorionic villus sampling), which is diagnostic, and (2) screening using the detection of abnormal ratios of free floating fetal chromosomes in the maternal blood. Women whose screening test suggests a high risk of aneuploidy could choose to undergo diagnostic invasive testing,
Age and obesity are risk factors for development of diabetes mellitus, as well as gestational diabetes.
Given the increased risk of congenital anomalies in older women, we feel a detailed second trimester ultrasound examination to look for significant structural abnormalities.
The clinician should discuss pregnancy complications that occur with increased frequency in older gravidae, such as spontaneous abortion, some congenital anomalies, placenta previa, gestational diabetes, preeclampsia, and cesarean delivery. Some of these complications may, in turn, result in preterm birth, so the implications of preterm birth should also be reviewed.
The patient's risk for adverse outcome, including preterm delivery/low birth weight, intrauterine growth restriction, and stillbirth, should be assessed by considering not only her age, but also the presence or absence of concomitant risk factors such as hypertension, diabetes, obesity, low socioeconomic status, black race, and previous pregnancy complicated by growth restriction or preterm birth.