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Pregnancy in Advanced Maternal Age

Advanced maternal age (AMA) has been defined traditionally as women >35 years at delivery. While this concept is still acceptable, more women are delaying childbirth to even later reproductive years due to social, educational and economic factors, which is a common phenomenon in the developed world. It is now possible for women to become pregnant in the very advanced reproductive ages with the advent of egg donation, egg freezing (fertility preservation) and IVF. Preconceptional counseling and management of women with AMA requires understanding of the effects of age, pre-existing co-morbidities and complications during pregnancy and delivery.

AMA is associated with a higher incidence of chronic illnesses such as hypertension, diabetes, presence of fibroids, risk of chromosomal abnormalities and miscarriage. They are also more likely to experience pregnancy related complications compared to younger women. These complications include pregnancy induced hypertension, diabetes, preeclampsia (hypertension and presence of protein in the urine), placental abruption (premature separation of the placenta), IUGR (intrauterine growth restriction), placenta previa (abnormal implantation of the placenta) and a higher incidence of cesarean delivery and related obstetrical complications.

There are no specific additional tests or set guidelines for prospective mothers of AMA in addition to the routine preconceptional testing that is applicable to all women in their age group. However, obtaining a detailed history, a complete physical exam and medical/cardiac evaluation are common practices in infertility patients of AMA. Such an evaluation will identify patients with hypertension and assess other problems, which can place the patient at an increased risk of complications during the pregnancy.

Historically, genetic testing by chorionic villus sampling (CVS) or amniocentesis was recommended almost on a regular basis for women above the age of 35. While this may still be the case in some clinical circumstances, first trimester screening has largely replaced second trimester screening for Down’s syndrome and Trisomy 18 screening. First trimester screening (nuchal translucency measurement, hCG and PAAP-A levels) does not allow testing for neural tube defects. In women greater than age 40, CVS or amniocentesis and mammogram are usually performed. If the patient is above the age of 45, in addition to the tests above, screening for diabetes, heart disease, thyroid disorders and lipid profile is reasonable. In women above the age of 50, additional testing may include a colonoscopy, advanced cardiac testing and a thorough medical evaluation including psychological assessment.

Dr. Bayrak recommends reproductive age-specific screening tests and medical evaluation with risk assessment following the initial consultation and prior to fertility treatment. Some patients may require additional testing based on their personal history and family background.

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