* Updated 10/2022
It is no secret that pregnancy rates are increasing in persons over age 40. Those who want to have children are putting things such as education, career advancement, and training before family building plans- myself included! I had my now 6-year old twins 9 days before I turned 43!
Inspired by this topic, I recently co-authored a paper with Christopher P. Moutos, MD, Phuong Ly, MD, and Dean M. Moutos, MD, entitled, “Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management From Preconception to Delivery.” This paper has since been approved for continuing medical education credit for obstetrical care providers.
As described in the objective of our paper, “After participating in this activity, the provider should be better able to explain the benefits of preconception counseling and workup for patients over age 40 desiring pregnancy; identify the impact of chronic medical conditions on pregnancy; and describe antenatal management by trimester for this patient population.”
➡️Offer an early diabetes screen.
➡️Consider low-dose aspirin for prevention of preeclampsia.
➡️Early ultrasound dating.
➡️Higher likelihood of early pregnancy loss (EPL).
➡️Counsel on prenatal screening and diagnostic testing.
➡️Patients pregnant with PGT normal embryos should still get prenatal screening and be offered diagnostic testing.
➡️Detailed anatomy scan and fetal echocardiogram by 22 weeks’ gestation.
➡️There is an increased risk of stillbirth that is higher than in those older than 35 years.
➡️Higher rates of gestational diabetes, hypertensive disorders of pregnancy and placenta previa.
➡️30X higher risk of cardiovascular-associated death.
➡️Patients with known pregnancy complications should have antepartum surveillance as indicated by those conditions.
➡️Consider antenatal surveillance in otherwise uncomplicated pregnancies as well.
➡️Due to increased risk of stillbirth, induction of labor at 39 weeks, or sooner if medically indicated, should be considered.
➡️As long as no maternal or fetal contraindications exist patients should be encouraged to attempt a vaginal delivery.
➡️Age alone is not an indication for a primary cesarean delivery.
But it is not only critical for obstetrical care providers to understand pregnancy over age 40–you should know as well!! I strongly believe that persons who are delaying childbearing for any reason should also understand the potential risks and complications associated with TTC and pregnancy over age 40. REI specialist, Dr. Aimee Eyvazzadeh of the Egg Whisperer Show agreed, so she invited me on to discuss the findings of my publication.
If someone is approaching age 40, your provider may or may not bring up the topic of childbearing at routine well-woman exams. If this is something you are considering, though, you should bring it up! There are many things to assess such as period regularity, egg quality vs. egg quantity, any pre-existing medical conditions, as well as medications you are taking on a chronic basis.
As one approaches age 40, there are several medical conditions that could require medications, including diabetes, chronic hypertension, or mental health conditions like anxiety or depression. In anticipation of pregnancy, you may need to switch to a different medication or adjust dosage. You should have a conversation about the risk-benefits of medications with your healthcare provider.In addition, I recommend that those approaching age 40 and considering childbearing have a cardiac evaluation completed. As discussed in the paper, one of the biggest physiologic changes during pregnancy is to the cardiovascular system. Persons with hypertension or other pre-existing conditions should get an EKG, and consideration for an echocardiogram. With preconception evaluations you and your medical providers are gaining valuable information. Being as knowledgeable and as informed is only going to help.
There are risks and complications for those who are TTC or pregnant over age 40. Making sure we are in as best possible health before conception is ideal, though I know that is not always possible when there are surprise pregnancies. Getting your routine exams can help ensure you understand your health should a surprise pregnancy occur!One of the biggest complications for those over age 40 is the actual ability to conceive. Just because you have had a family member who conceived and delivered a healthy baby over age 40 does not mean the same will be true for you–and vice versa. A Reproductive Endocrinology and Infertility (REI) specialist is a medical doctor with advanced training in the science of fertility. I would recommend that you don’t delay going to see an REI specialist because you are scared of hearing something bad or think that it will mean you cannot conceive spontaneously. Going to an REI specialist sooner rather than later can help you gain valuable insight and information that may help you in your conception goals.
Don’t forget, start having the discussions as soon as possible with your ObGyn if you are considering delayed childbearing. It can help tremendously to give you the best options and possible chances of a healthy pregnancy.
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.
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