Transcript Problems in pregnancy with advancing age

Risks and Complications of
Pregnancy with Increasing
Age
Katie Spencer
Advisor: D. French
Overview
Do mothers of advancing age (≥ 35) have
increased risks associated with
pregnancy?
What risks do they have?
How do we educate our patients to
minimize these risks?
Do women of advancing age have
increased risks in pregnancy?
All pregnancies carry some form of risk to the
mother and baby.
Some of these risks increase as the age of the
mother increases.
Women 35 and over have more risks associated
with pregnancy than younger women.
Older women may have more comorbid
conditions that contribute to pregnancy risks.
What are some of these increasing
risks?
Abruptio placentae - the implanted placenta
prematurely separates from the uterine wall.
Associated with hypertension, trauma, increased
amounts of amniotic fluid, multiples, and cocaine
use.
Placenta previa - placenta is positioned close to
or over the internal cervical os. Abnormal
vascularization is thought to play a part.
Associated with previous C-section, increased
maternal age, and increased number of previous
pregnancies.
What are some of these increasing
risks?
Preeclampsia – mother develops
sustained HTN (systolic ≥ 140 mmHg or
diastolic ≥ 90 mmHg) with proteinuria
brought on by pregnancy, usually in the
second half of gestation. It can affect
many of the mother’s body systems, and
can cause problems with the fetus by
decreasing placental perfusion. Associated
with previous miscarriage and the
extremes of reproductive age.
What are some of these increasing
risks?
Eclampsia – usually occurs in a woman who has
preeclampsia. The defining characteristic is
convulsions not caused by a neurological
disorder. Most cases occur within 24 hrs of
delivery, but can happen up to 10 days after
birth. Can cause maternal death.
Chronic hypertension – mother has HTN before
the 20th week of gestation, or beyond 6 weeks
after delivery. Usually caused by essential HTN,
the risk for which increases with age. Increases
risk of developing preeclampsia and eclampsia.
What are some of these increasing
risks?
Diabetes – type I, type II, or gestational diabetes
can occur in pregnancy. Diabetes in pregnancy
can lead to preeclampsia. It can also cause
ketoacidosis and retinopathy in the mother. It
can lead to congenital anomalies, IUGR,
macrosomia (> 4000 g) which can cause
problems in delivery, and can lead to a
hypoglycemic neonate. Uncontrolled diabetes
during pregnancy increases the risk of
spontaneous abortion (< 20 wks) and stillbirth (≥
20 wks). Type II diabetes may be a comorbidity
in a mother of advancing age.
What are some of these increasing
risks?
Chromosomal abnormalities - may be due to the deteriorating quality
of the ova with advancing age (Heffner, 2004).
Types of abnormalities:

Down syndrome (trisomy 21)

Edwards syndrome (trisomy 18)

Kleinfelter syndrome (sex chromosome polysomy)

many others
Each of these chromosomal abnormalities causes different
characteristic changes of the fetus, various mental changes, and
altered life expectancies of the neonate.
The incidence of Down syndrome among all newborns is about
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).
Men with advancing paternal age also have an increased risk of
producing a child with an autosomal dominant disease, like
Marfan syndrome, because of increased genetic mutations
(Heffner, 2004).
What are some of these increasing
risks?
Infertility – can be caused by maternal
issues associated with age such as
premature ovarian failure, perimenopause,
and menopause. Can also be due to
anovulation, anatomical defects, or a
variety of other problems in the female.
May also be due to abnormal
spermatogenesis in the male.
How can you counsel your
patients?
Preconception:
Healthy diet- prenatal vitamins and folic acid
Moderate exercise
Women who have a BMI over 29 have increased
risks, regardless of age, including preeclampsia,
thromboembolism, C-section, wound infection,
and anesthesia complications (Montan, 2007).
Refraining from drinking, smoking, and drugs
Counsel mother on obtaining prenatal care
How can you counsel your
patients?
Comorbidities – educate pts on lifestyle
modifications. Urge them to get their
conditions under control before becoming
pregnant.
Medications – educate pts about their
medications (Rx, OTC, and supplements).
Determine pregnancy categories and risk
vs benefit. Decide if certain meds need to
be changed or stopped.
How can you counsel your
patients?
Genetic counseling – The goal is to collect
information from your patient to assess the risk
of the mother developing disease or conceiving
an infant with congenital abnormalities, to inform
your patient of screening and diagnostic tests
that are available to them, and also to discuss
alternative reproductive options, if necessary.
Use easily understood language, and answer all
questions to the patient’s satisfaction. The
counseling should be informative and supportive
to the patient, but free of personal opinion.
(Beckmann et al., 2006).
How can you counsel and manage
your patients?
During Pregnancy
Encourage mother to get good prenatal
care
Screen for diabetes
Screen for hypertension
Do Maternal serum alpha fetoprotein
(MSAFP) to screen for neural tube defects
How can you counsel and manage
your patients?
Mothers who are at higher risk of having a child
with congenital abnormalities, based on their
genetic counseling, may consider screening
tests or fetal chromosome analysis early in
pregnancy.
Amniocentesis – done at 15-20 wks gestation,
needle guided by ultrasound removes 20-40 mL
of amniotic fluid. Cells in the fluid are cultured
and examined. Neural tube defects can also be
detected by examining the fluid.
How can you counsel and manage
your patients?
Chorionic Villus Sampling – 10-12 wks,
immature placental tissue is aspirated guided by
ultrasound. The cells can be examined for
chromosomal abnormalities. Neural tube
defects cannot be detected.
Other tests that are more invasive, such as fetal
skin sampling, fetal tissue biopsy, and fetoscopy
can be used for diagnosis of rare disorders that
cannot be diagnosed by other tests.
How can you counsel your
patients?
Labor and Delivery
Decreased placental function can lead to low birth
weight (<2,500 g) neonates.
IUGR can also lead to low birth weights or preterm
births.
Increasing age is related to preterm birth (<37 wks).
Mothers of advancing age are more likely to deliver by
C-section. This may be due to the care providers
having a lower threshold of intervention with mothers
of advancing age, the increased likelihood of breech
presentation, or that older mothers are more likely to
have post partum hemorrhage if they deliver vaginally
(Jolly et al., 2000).
How can you counsel your
patients?
Post-partum
The mother of advancing age may have a longer
recovery time from vaginal or caesarean birth,
as her body needs extra time to heal damaged
tissues. She may need extra time in the hospital
or at home to recover before returning to usual
activities.
Mothers should be given information on proper
development of the baby, breastfeeding, bonding
with the baby, and her health. She should also
be given resources about nutrition, exercise,
handling stress, and depression.
How can you counsel your
patients?
If the newborn does have chromosomal or
congenital abnormalities, the family needs to be
counseled on the course of the condition and
what to expect. They should also be given
resources for finding information and support
groups, and dealing with the stress of this event.
Any complications that occur with pregnancy
may require professional counseling for the
patient, as well as empathy from the health care
provider.
Conclusions
Mothers of advancing age may have a
number of increased risks surrounding
pregnancy to consider before conception
and during pregnancy. The risks in each
stage of the process are increased in
comparison to their younger counterparts.
Conclusions
It is certainly possible for these women to
conceive, have healthy pregnancies, and
to bear healthy babies. Advancing age is
not a reason to abstain from becoming
pregnant, but it does carry increased risks
that should be discussed and watched for
by the practitioner and the patient.
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