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Optimal obstetric care for women aged 40 and older

OBG Management. 2014 November;26(11):28,30,32-34,36,37,e1
November 4, 2014|OBG Management
John R. Barton, MD;Baha M. Sibai, MD
Author and Disclosure Information

John R. Barton, MD, and Baha M. Sibai, MD

Dr. Barton is Director of Maternal-Fetal Medicine at Baptist Health Lexington in Lexington, Kentucky.

Dr. Sibai is Professor of Maternal-Fetal Medicine (MFM) and Director of the MFM Fellowship Program, Department of Obstetrics, Gynecology, and Reproductive Sciences, at the University of Texas Medical School at Houston, Texas.

Dr. Barton reports that he receives grant or research support from Alere, and that he is on the clinical advisory board of NX PharmaGen Inc.

Dr. Sibai reports no financial relationships relevant to this article.

As the trend toward delayed childbearing continues, ObGyns will encounter more pregnancies among patients of advanced maternal age. Here, a guide for assessing risks and managing pregnancy and delivery.

For an overview of evaluation and management of pregnant women aged 40 or older, see TABLE 4.

TAble 4: Evaluation and management of the pregnant woman older than age 40

Preconception

  • Identify risk factors (ie, diabetes, obesity, hypertension, cardiac dysfunction, family history
  • Review outcome of previous pregnancy, if applicable
  • Review risks (multiple gestation, birth defects) associated with assisted reproductive technologies if they were needed to achieve pregnancy
  • Optimize maternal health
  • Begin folic acid supplementation
  • Encourage smoking cessation
  • If the patient is ≥45 years old:
    – Electrocardiogram
    – Glucose screening (fasting plasma glucose or hemoglobin A1c)
    – Echocardiogram for patients with chronic hypertension

 First trimester

  • Ultrasonography for dating and to assess fetal number and chorionicity
  • Baseline metabolic profile and complete blood count
  • Baseline urinalysis
  • Continue folic acid supplementation
  • Offer first-trimester genetic testing or other genetic screening

Second trimester

  • If first-trimester genetic testing is declined, offer second-trimester testing or screening
  • Detailed fetal anomaly evaluation by ultrasound
  • Fetal echocardiogram if pregnancy was achieved by in vitro fertilization or if it is a monochorionic twin gestation
  • Screen for gestational diabetes

Third trimester

  • Increased antenatal testing for routine indications, including hypertension, diabetes, and lupus
  • Ultrasonography for growth and later ultrasonographic findings of fetal aneuploidy
  • Consider delivery

Share your thoughts on this article! Send your Letter to the Editor to rbarbieri@frontlinemedcom.com. Please include your name and the city and state in which you practice.

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