Risks and Complications of Pregnancy with Increasing Age Katie Spencer Advisor: D. French.

Risks and Complications of Risks and Complications of Pregnancy with Increasing Pregnancy with Increasing

AgeAge

Katie SpencerKatie Spencer

Advisor: D. FrenchAdvisor: D. French

OverviewOverview

Do mothers of advancing age (≥ 35) have Do mothers of advancing age (≥ 35) have increased risks associated with increased risks associated with pregnancy?pregnancy?

What risks do they have?What risks do they have?

How do we educate our patients to How do we educate our patients to minimize these risks?minimize these risks?

Do women of advancing age have Do women of advancing age have increased risks in pregnancy?increased risks in pregnancy?

All pregnancies carry some form of risk to the All pregnancies carry some form of risk to the mother and baby.mother and baby.

Some of these risks increase as the age of the Some of these risks increase as the age of the mother increases. mother increases.

Women 35 and over have more risks associated Women 35 and over have more risks associated with pregnancy than younger women. with pregnancy than younger women.

Older women may have more comorbid Older women may have more comorbid conditions that contribute to pregnancy risks.conditions that contribute to pregnancy risks.

What are some of these increasing What are some of these increasing risks?risks?

Abruptio placentaeAbruptio placentae - the implanted placenta - the implanted placenta prematurely separates from the uterine wall. prematurely separates from the uterine wall. Associated with hypertension, trauma, increased Associated with hypertension, trauma, increased amounts of amniotic fluid, multiples, and cocaine amounts of amniotic fluid, multiples, and cocaine use.use.Placenta previaPlacenta previa - placenta is positioned close to - placenta is positioned close to or over the internal cervical os. Abnormal or over the internal cervical os. Abnormal vascularization is thought to play a part. vascularization is thought to play a part. Associated with previous C-section, increased Associated with previous C-section, increased maternal age, and increased number of previous maternal age, and increased number of previous pregnancies.pregnancies.


PreeclampsiaPreeclampsia – mother develops – mother develops sustained HTN (systolic ≥ 140 mmHg or sustained HTN (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg) with proteinuria diastolic ≥ 90 mmHg) with proteinuria brought on by pregnancy, usually in the brought on by pregnancy, usually in the second half of gestation. It can affect second half of gestation. It can affect many of the mother’s body systems, and many of the mother’s body systems, and can cause problems with the fetus by can cause problems with the fetus by decreasing placental perfusion. decreasing placental perfusion. Associated with previous miscarriage and Associated with previous miscarriage and the extremes of reproductive age.the extremes of reproductive age.


EclampsiaEclampsia – usually occurs in a woman who has – usually occurs in a woman who has preeclampsia. The defining characteristic is preeclampsia. The defining characteristic is convulsions not caused by a neurological convulsions not caused by a neurological disorder. Most cases occur within 24 hrs of disorder. Most cases occur within 24 hrs of delivery, but can happen up to 10 days after delivery, but can happen up to 10 days after birth. Can cause maternal death.birth. Can cause maternal death.Chronic hypertensionChronic hypertension – mother has HTN before – mother has HTN before the 20the 20thth week of gestation, or beyond 6 weeks week of gestation, or beyond 6 weeks after delivery. Usually caused by essential HTN, after delivery. Usually caused by essential HTN, the risk for which increases with age. Increases the risk for which increases with age. Increases risk of developing preeclampsia and eclampsia.risk of developing preeclampsia and eclampsia.


DiabetesDiabetes – type I, type II, or gestational diabetes – type I, type II, or gestational diabetes can occur in pregnancy. Diabetes in pregnancy can occur in pregnancy. Diabetes in pregnancy can lead to preeclampsia. It can also cause can lead to preeclampsia. It can also cause ketoacidosis and retinopathy in the mother. It ketoacidosis and retinopathy in the mother. It can lead to congenital anomalies, IUGR, can lead to congenital anomalies, IUGR, macrosomia (> 4000 g) which can cause macrosomia (> 4000 g) which can cause problems in delivery, and can lead to a problems in delivery, and can lead to a hypoglycemic neonate. Uncontrolled diabetes hypoglycemic neonate. Uncontrolled diabetes during pregnancy increases the risk of during pregnancy increases the risk of spontaneous abortion (< 20 wks) and stillbirth (≥ spontaneous abortion (< 20 wks) and stillbirth (≥ 20 wks). Type II diabetes may be a comorbidity 20 wks). Type II diabetes may be a comorbidity in a mother of advancing age. in a mother of advancing age.


Chromosomal abnormalities Chromosomal abnormalities - may be due to the deteriorating quality - may be due to the deteriorating quality of the ova with advancing age (Heffner, 2004). of the ova with advancing age (Heffner, 2004). Types of abnormalities:Types of abnormalities: Down syndrome (trisomy 21)Down syndrome (trisomy 21) Edwards syndrome (trisomy 18)Edwards syndrome (trisomy 18) Kleinfelter syndrome (sex chromosome polysomy)Kleinfelter syndrome (sex chromosome polysomy) many othersmany othersEach of these chromosomal abnormalities causes different Each of these chromosomal abnormalities causes different

characteristic changes of the fetus, various mental changes, and characteristic changes of the fetus, various mental changes, and altered life expectancies of the neonate. altered life expectancies of the neonate.

The incidence of Down syndrome among all newborns is about The incidence of Down syndrome among all newborns is about 1:800. For mothers age 35, the incidence is 1:385, and for 1:800. For mothers age 35, the incidence is 1:385, and for mothers age 45, the incidence is 1:33 (Beckmann et al., 2006). mothers age 45, the incidence is 1:33 (Beckmann et al., 2006).

Men with advancing paternal age also have an increased risk of Men with advancing paternal age also have an increased risk of producing a child with an autosomal dominant disease, like producing a child with an autosomal dominant disease, like Marfan syndrome, because of increased genetic mutations Marfan syndrome, because of increased genetic mutations (Heffner, 2004). (Heffner, 2004).


InfertilityInfertility – can be caused by maternal – can be caused by maternal issues associated with age such as issues associated with age such as premature ovarian failure, perimenopause, premature ovarian failure, perimenopause, and menopause. Can also be due to and menopause. Can also be due to anovulation, anatomical defects, or a anovulation, anatomical defects, or a variety of other problems in the female. variety of other problems in the female. May also be due to abnormal May also be due to abnormal spermatogenesis in the male.spermatogenesis in the male.

How can you counsel your How can you counsel your patients?patients?

Preconception:Preconception:

Healthy diet- prenatal vitamins and folic acid Healthy diet- prenatal vitamins and folic acid

Moderate exercise Moderate exercise

Women who have a BMI over 29 have increased Women who have a BMI over 29 have increased risks, regardless of age, including preeclampsia, risks, regardless of age, including preeclampsia, thromboembolism, C-section, wound infection, thromboembolism, C-section, wound infection, and anesthesia complications (Montan, 2007). and anesthesia complications (Montan, 2007).

Refraining from drinking, smoking, and drugsRefraining from drinking, smoking, and drugs

Counsel mother on obtaining prenatal careCounsel mother on obtaining prenatal care


ComorbiditiesComorbidities – educate pts on lifestyle – educate pts on lifestyle modifications. Urge them to get their modifications. Urge them to get their conditions under control before becoming conditions under control before becoming pregnant.pregnant.MedicationsMedications – educate pts about their – educate pts about their medications (Rx, OTC, and supplements). medications (Rx, OTC, and supplements). Determine pregnancy categories and risk Determine pregnancy categories and risk vs benefit. Decide if certain meds need to vs benefit. Decide if certain meds need to be changed or stopped.be changed or stopped.


Genetic counselingGenetic counseling – The goal is to collect – The goal is to collect information from your patient to assess the risk information from your patient to assess the risk of the mother developing disease or conceiving of the mother developing disease or conceiving an infant with congenital abnormalities, to inform an infant with congenital abnormalities, to inform your patient of screening and diagnostic tests your patient of screening and diagnostic tests that are available to them, and also to discuss that are available to them, and also to discuss alternative reproductive options, if necessary. alternative reproductive options, if necessary. Use easily understood language, and answer all Use easily understood language, and answer all questions to the patient’s satisfaction. The questions to the patient’s satisfaction. The counseling should be informative and supportive counseling should be informative and supportive to the patient, but free of personal opinion. to the patient, but free of personal opinion. (Beckmann et al., 2006). (Beckmann et al., 2006).

How can you counsel and manage How can you counsel and manage your patients?your patients?

During PregnancyDuring Pregnancy

Encourage mother to get good prenatal Encourage mother to get good prenatal carecare

Screen for diabetesScreen for diabetes

Screen for hypertensionScreen for hypertension

Do Maternal serum alpha fetoprotein Do Maternal serum alpha fetoprotein (MSAFP) to screen for neural tube defects(MSAFP) to screen for neural tube defects


Mothers who are at higher risk of having a child Mothers who are at higher risk of having a child with congenital abnormalities, based on their with congenital abnormalities, based on their genetic counseling, may consider screening genetic counseling, may consider screening tests or fetal chromosome analysis early in tests or fetal chromosome analysis early in pregnancy. pregnancy.

AmniocentesisAmniocentesis – done at 15-20 wks gestation, – done at 15-20 wks gestation, needle guided by ultrasound removes 20-40 mL needle guided by ultrasound removes 20-40 mL of amniotic fluid. Cells in the fluid are cultured of amniotic fluid. Cells in the fluid are cultured and examined. Neural tube defects can also be and examined. Neural tube defects can also be detected by examining the fluid.detected by examining the fluid.


Chorionic Villus SamplingChorionic Villus Sampling – 10-12 wks, – 10-12 wks, immature placental tissue is aspirated guided by immature placental tissue is aspirated guided by ultrasound. The cells can be examined for ultrasound. The cells can be examined for chromosomal abnormalities. Neural tube chromosomal abnormalities. Neural tube defects cannot be detected.defects cannot be detected.

Other tests that are more invasive, such as fetal Other tests that are more invasive, such as fetal skin sampling, fetal tissue biopsy, and fetoscopy skin sampling, fetal tissue biopsy, and fetoscopy can be used for diagnosis of rare disorders that can be used for diagnosis of rare disorders that cannot be diagnosed by other tests.cannot be diagnosed by other tests.


Labor and DeliveryLabor and DeliveryDecreased placental function can lead to low birth Decreased placental function can lead to low birth weight (<2,500 g) neonates.weight (<2,500 g) neonates.IUGR can also lead to low birth weights or preterm IUGR can also lead to low birth weights or preterm births.births.Increasing age is related to preterm birth (<37 wks).Increasing age is related to preterm birth (<37 wks).Mothers of advancing age are more likely to deliver by Mothers of advancing age are more likely to deliver by C-section. This may be due to the care providers C-section. This may be due to the care providers having a lower threshold of intervention with mothers having a lower threshold of intervention with mothers of advancing age, the increased likelihood of breech of advancing age, the increased likelihood of breech presentation, or that older mothers are more likely to presentation, or that older mothers are more likely to have post partum hemorrhage if they deliver vaginally have post partum hemorrhage if they deliver vaginally (Jolly et al., 2000).(Jolly et al., 2000).


Post-partumPost-partumThe mother of advancing age may have a longer The mother of advancing age may have a longer recovery time from vaginal or caesarean birth, recovery time from vaginal or caesarean birth, as her body needs extra time to heal damaged as her body needs extra time to heal damaged tissues. She may need extra time in the hospital tissues. She may need extra time in the hospital or at home to recover before returning to usual or at home to recover before returning to usual activities.activities.Mothers should be given information on proper Mothers should be given information on proper development of the baby, breastfeeding, development of the baby, breastfeeding, bonding with the baby, and her health. She bonding with the baby, and her health. She should also be given resources about nutrition, should also be given resources about nutrition, exercise, handling stress, and depression. exercise, handling stress, and depression.


If the newborn does have chromosomal or If the newborn does have chromosomal or congenital abnormalities, the family needs to be congenital abnormalities, the family needs to be counseled on the course of the condition and counseled on the course of the condition and what to expect. They should also be given what to expect. They should also be given resources for finding information and support resources for finding information and support groups, and dealing with the stress of this event.groups, and dealing with the stress of this event.

Any complications that occur with pregnancy Any complications that occur with pregnancy may require professional counseling for the may require professional counseling for the patient, as well as empathy from the health care patient, as well as empathy from the health care provider.provider.

ConclusionsConclusions

Mothers of advancing age may have a Mothers of advancing age may have a number of increased risks surrounding number of increased risks surrounding pregnancy to consider before conception pregnancy to consider before conception and during pregnancy. The risks in each and during pregnancy. The risks in each stage of the process are increased in stage of the process are increased in comparison to their younger counterparts. comparison to their younger counterparts.

ConclusionsConclusions

It is certainly possible for these women to It is certainly possible for these women to conceive, have healthy pregnancies, and conceive, have healthy pregnancies, and to bear healthy babies. Advancing age is to bear healthy babies. Advancing age is not a reason to abstain from becoming not a reason to abstain from becoming pregnant, but it does carry increased risks pregnant, but it does carry increased risks that should be discussed and watched for that should be discussed and watched for by the practitioner and the patient.by the practitioner and the patient.

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Risks and Complications of Pregnancy with Increasing Age Katie Spencer Advisor: D. French.

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