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Risks Called Manageable for the Mature Gravida : Consider treating every visit as a preconception visit because many later pregnancies are unintended.


 

ASHEVILLE, N.C. — The potential pitfalls around conception and childbirth can be daunting—and more so in women over age 35—but the physician can help ensure better outcomes by addressing concerns head-on and being supportive, said Dr. James E. Ferguson II at the Southern Obstetric and Gynecologic Seminar.

Patients would be better served if physicians approached the situation with optimism rather than pessimism, despite increasing odds against successful conception and complication-free childbirth as women age, he said.

It's no secret that pregnancies are being delayed, said Dr. Ferguson, chairman of the obstetrics and gynecology department at the University of Kentucky.

Data on older mothers generally show that postpartum and intrapartum complications—such as obstructed labor, prolonged labor, preeclampsia, and prematurity—are much higher in women over age 40, compared with those aged 20–29, he said.

But there are some contradictions. For instance, the First and Second Trimester Evaluation of Risk of Aneuploidy (FASTER) study, conducted from 1999 to 2002, found no difference in gestational hypertension or preeclampsia between the under- and over-35 groups (Obstet. Gynecol. 2005;105:983–90). One caveat: The study population was mostly healthy, wealthy, and white, said Dr. Ferguson. The risk of spontaneous abortion was higher in the over-40 group, as were chromosomal abnormalities, low birth weight, and perinatal loss.

The likelihood of both maternal and fetal death also increases with age, Dr. Ferguson noted. But it doesn't have to be all bad news, he said. For instance, a mid-1990s study found that there were 4 fetal deaths per 1,000 live births in 34-year-old mothers, compared with 6–9 per 1,000 in 39-year-old mothers (N. Engl. J. Med. 1995;333:1,002–4). Viewed from an individual's perspective, those aren't such bad odds, said Dr. Ferguson. “I personally find this very reassuring rather than very frightening,” he said.

Similarly, though maternal deaths increase significantly after age 39, the rate per 100,000 live births overall is still fairly low, said Dr. Ferguson. Compared with 25- to 29-year-olds, the relative risk of death is 2.3 for the 35- to 39-year-olds and 5.0 for women over 40, according to one study (Obstet. Gynecol. 2003;101:1,015–21). “It's much less significant than it is in the patient's mind,” he said, adding, “You can reassure her.”

Causes of death include pulmonary embolism, pregnancy-induced hypertension, and hemorrhage, either related or not related to ectopic pregnancy. Women over age 40 are at risk because of increased incidence of underlying medical conditions, more postpartum complications, and a higher likelihood of cesarean section. There have been few studies in women over 45, but the few conducted have shown that about half the pregnancies involved complications, and that the risk was much greater for first-time mothers.

Because of the common tendency to put off childbearing—and because almost half of pregnancies are unintended—gynecologists might consider treating every patient office visit as a preconception visit, said Dr. Ferguson.

Patients should be quizzed about medical and immunization histories, and counseled on risks and genetic testing. Physicians should also offer help with reducing risky behavior like smoking and alcohol use.

Women should also be made aware of the latest research on birth spacing—a child born less than 18 months or more than 50 months after the previous birth has a greater risk of bad perinatal outcome, he noted (JAMA 2006;295:1809–23).

For the older mother, “there are some special risks, but I think they are manageable,” Dr. Ferguson said.

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