Management of pregnancy in women of advanced age
- Ruth C Fretts, MD, MPH
Ruth C Fretts, MD, MPH
- Assistant Professor of Obstetrics & Gynecology
- Harvard Medical School
Women who delay childbearing are at increased risk of pregnancy complications, including 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. Benefits include that older couples tend to be more emotionally mature and financially stable than when they were younger. 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.
This topic will address the management of pregnancy in women of advanced age, which is generally agreed upon as age ≥35 years. Related topics on the effects of advanced age on pregnancy and fertility are presented separately.
Advanced maternal age — The age cut-off for advanced maternal age (AMA) pregnancy is not uniformly defined. Historically, AMA was defined as maternal age ≥ 35 years based on the convergence of the risk of fetal Down syndrome and the risk of amniocentesis to assess for Down syndrome. Other studies have defined AMA as age 40 or greater, and a category of "very advanced maternal age" has been proposed for women ≥45 years or ≥50 years, depending on the study [1,2].
- Fitzpatrick KE, Tuffnell D, Kurinczuk JJ, Knight M. Pregnancy at very advanced maternal age: a UK population-based cohort study. BJOG 2016.
- Waldenström U, Cnattingius S, Vixner L, Norman M. Advanced maternal age increases the risk of very preterm birth, irrespective of parity: a population-based register study. BJOG 2016.
- Haslinger C, Stoiber B, Capanna F, et al. Postponed pregnancies and risks of very advanced maternal age. Swiss Med Wkly 2016; 146:w14330.
- Mathews TJ, Hamilton BE. Mean age of mother, 1970-2000. Natl Vital Stat Rep 2002; 51:1.
- Hamilton BE, Martin JA, Osterman MJ, et al. Births: Final Data for 2014. Natl Vital Stat Rep 2015; 64:1.
- Bacak SJ, Callaghan WM, Dietz PM, Crouse C. Pregnancy-associated hospitalizations in the United States, 1999-2000. Am J Obstet Gynecol 2005; 192:592.
- Nybo Andersen AM, Wohlfahrt J, Christens P, et al. Maternal age and fetal loss: population based register linkage study. BMJ 2000; 320:1708.
- Khalil A, Syngelaki A, Maiz N, et al. Maternal age and adverse pregnancy outcome: a cohort study. Ultrasound Obstet Gynecol 2013; 42:634.
- Solomon CG, Willett WC, Carey VJ, et al. A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA 1997; 278:1078.
- Savva GM, Walker K, Morris JK. The maternal age-specific live birth prevalence of trisomies 13 and 18 compared to trisomy 21 (Down syndrome). Prenat Diagn 2010; 30:57.
- Pettit KE, Hull AD, Korty L, et al. Noninvasive prenatal testing: a replacement for chorionic villus sampling and amniocentesis for advanced maternal age? Obstet Gynecol 2014; 123 Suppl 1:165S.
- Jacobsson B, Ladfors L, Milsom I. Advanced maternal age and adverse perinatal outcome. Obstet Gynecol 2004; 104:727.
- Joseph KS, Allen AC, Dodds L, et al. The perinatal effects of delayed childbearing. Obstet Gynecol 2005; 105:1410.
- Centre for maternal and child enquiries (CMACE) perinatal mortality 2009. CMACE, London, 2011.
- Reddy UM, Laughon SK, Sun L, et al. Prepregnancy risk factors for antepartum stillbirth in the United States. Obstet Gynecol 2010; 116:1119.
- Fox NS, Rebarber A, Silverstein M, et al. The effectiveness of antepartum surveillance in reducing the risk of stillbirth in patients with advanced maternal age. Eur J Obstet Gynecol Reprod Biol 2013; 170:387.
- Dhanjal MK, Kenyon A. Induction of Labour at Term in Older Mothers. Scientific Impact Paper No. 34, Royal College of Obstetricians and Gynaecologists; London, UK, 2013.
- Page JM, Snowden JM, Cheng YW, et al. The risk of stillbirth and infant death by each additional week of expectant management stratified by maternal age. Am J Obstet Gynecol 2013; 209:375.e1.
- Reddy UM, Ko CW, Willinger M. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Am J Obstet Gynecol 2006; 195:764.
- Hedegaard M, Lidegaard Ø, Skovlund CW, et al. Reduction in stillbirths at term after new birth induction paradigm: results of a national intervention. BMJ Open 2014; 4:e005785.
- Smith GC. Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies. Am J Obstet Gynecol 2001; 184:489.
- Walker KF, Bugg GJ, Macpherson M, et al. Randomized Trial of Labor Induction in Women 35 Years of Age or Older. N Engl J Med 2016; 374:813.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 561: Nonmedically indicated early-term deliveries. Obstet Gynecol 2013; 121:911. Reaffirmed July 2017.
- Gülmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev 2012; :CD004945.
- Walker KF, Malin G, Wilson P, Thornton JG. Induction of labour versus expectant management at term by subgroups of maternal age: an individual patient data meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 197:1.
- Nicholson JM, Kellar LC, Kellar GM. The impact of the interaction between increasing gestational age and obstetrical risk on birth outcomes: evidence of a varying optimal time of delivery. J Perinatol 2006; 26:392.
- Advanced maternal age
- Very advanced maternal age and implications
- INCIDENCE OF BIRTHS TO OLDER WOMEN
- RISK OF MISCARRIAGE
- SPECIFIC PRENATAL CARE ISSUES
- First and second trimester
- Third trimester
- Risks of stillbirth versus delivery
- - Induction of labor
- SUMMARY AND RECOMMENDATIONS