Ep 177: How Age Affects Pregnancy

Dr. Nicole (00:00): What is advanced maternal age, what are the exact risks for pregnancy and birth for someone who's advanced maternal age? And how does your pregnancy care including your labor and birth management change because of advanced maternal age, you're going to learn all of that in today's episode of the podcast. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Dr. Nicole (01:02): Well, hello. Hello. Welcome to another episode of the podcast. This is episode number 177. I am so glad you're spending some time with me today. So I have talked about advanced maternal age before in the context of genetic testing. I talked about that in episode 49, and again, in episode 146 of the podcast, but I realized that I'd never actually done an episode solely focused on the topic of advanced maternal age. So after having what feels like a lot of requests for it recently, I decided to do it today. So in this episode of the podcast, you're going to learn the definition of advanced maternal age spoiler alert. It is not as straightforward as you may think. You'll learn how common pregnancy is over the age of 35, the effects of being at an advanced maternal age, the effects on pregnancy, like some of the things that can happen, some of the increased risk that can happen during pregnancy because of advanced maternal age.

Dr. Nicole (02:04): And then finally we will end with how pregnancy care is managed differently because of advanced maternal age and spoiler alert. It is not as different as you might think. Now, regardless of your age, everybody, and I mean, everybody needs comprehensive childbirth education so that you can go into your birth prepared for the things that may come your way during your birth. And I happen to have an outstanding option that is called the Birth Preparation Course, my signature online childbirth education class that will get you calm, confident, and empowered to have a beautiful birth in the hospital. And keep in mind that the course is not focused like on making sure you have a specific outcome, because none of us can guarantee a specific outcome for birth. Birth is a very unpredictable process, but you will be able to manage that unpredictability. You will be able to control the things that you can control, and that will leave you feeling good, feeling satisfied with your birth experience, regardless of how things unfold.

Dr. Nicole (03:11): I really wish I could guarantee that everyone has a specific experience for their birth, but unfortunately that's just not possible, but I can guarantee that you'll be prepared. You'll be ready. You'll feel calm. You'll feel at peace going into your birth with the education in the Birth Preparation Course. So do check out the Birth Preparation Course. You can get all the details at drnicolerankins.com/enroll. All right, let's talk about advanced maternal age and pregnancy. Okay. So I know the code for that. It used to be, it may still be geriatric pregnancy, which I think is so absolutely ridiculous and disrespectful. Um, but it's, I'm going to say advanced maternal age in pregnancy, there actually is no universally accepted definition of advanced reproductive age in women. We know that fertility declines with advancing age, especially after 35, definitely after 40. And we know that women who get pregnant at later ages are at greater risk of pregnancy complications, but the age cutoff for advanced maternal age is not universally defined.

Dr. Nicole (04:22): Historically, it had been defined as a maternal age of greater than, or equal to 35 at the time of delivery delivery. And that had ba that was based on the risk of having a baby with down syndrome, being the same as the risk of having an amniocentesis to assess for down syndrome. Those two risk were the same at greater than 35. And that's where the age 35 came in. Like, that's it. And that's actually based on older data because the risk of amniocentesis is actually much lower nowadays, um, than what was in previous studies. So it was really an arbitrary definition. Other studies have defined advanced maternal age as 40 or greater. Now it should be, it's really important for you to understand that 35 or even 40 is not like a magic number. It's really a spectrum. And it's a continuum as age increases.

Dr. Nicole (05:25): The risk is going to increase. So do not think that, you know, the day before you're 34 and then you're 35 that magically suddenly risks are gonna increase. That is not how it works. Same thing with 39 and 40, it's really a spectrum and things continue to go up. Now you are here. When I talk about in a lot of the data, um, older studies often grouped everyone older than 35 together. Newer studies, uh, separated folks out, including and separated out people who are 40 and older, because you'll see that most of the risk regarding being older in pregnancy is actually in the 40 and older category. So I'll go back and forth when I'm describing some of the data in terms of, am I talking about 35 and older, 40 and older, and that's just based on what data is available, but I want you to really take away from this, that it is not like, boom, you hit 35.

Dr. Nicole (06:21): All of a sudden the risks like suddenly go up, it's really a spectrum and a continuum. And the other super duper important thing that I want you to take away from this is that studies have shown that most women over the age of 35, actually over the age of 45 and even over the age of 50 have good pregnancy outcomes. Okay. They have good pregnancy outcomes. That's why you can see women who do IVF in their fifties or late forties because studies show that they will still have good outcomes. Okay. So although you need to be aware of the risk, the data shows that the most likely thing is a good outcome, but again, we're gonna talk about all of the risk, um, uh, in the episode today. So how frequent are births happening to women aged 35 and older? So data from the Centers for Disease Control and prevention from 2020 shows that 11% of first time pregnancies in the US in 2020 were in women who were aged 35 or older.

Dr. Nicole (07:32): And 19% of all pregnancies were in women who were aged 35 and older. So more and more women there's been a continued upward trend in the mean age of pregnant folks in the US. And that is thought to be due to a number of reasons. One, there's just an increased population of women who are aged 35 to 45. Also women are getting married later, or there may be a second marriage. There are better contraceptive options. So people have the ability to plan pregnancy better. There's also much better educational opportunities for women, career advancement for women. In fact, maternal education is one of the strongest predictors of using birth control, of timing childbearing, and the total number of children that a woman will have a college educated woman will tend to have very low birth weight rates in their twenties and then higher first birth rates in their thirties.

Dr. Nicole (08:29): And that just kind of reflects delaying childbearing until you've completed your education or career opportunities. And then when looking at surveys of women, women have said that they want to have financial stability, achieve some personal goals, um, maybe be a stable marital relationship before planning pregnancy. Now on the flip side of that older women actually also have a higher prevalence of not using contraception, um, compared to younger women. And some of that is from the belief in thinking that they can't get pregnant over a certain age, especially over 40. So although women under the age of 25 have the highest rate of unintended pregnancy, women who are 35 years and older have the highest proportion of unintended pregnancies that end in abortion. So having surprise pregnancies, and then those pregnancies ending in abortion, um, sometimes it, it gets misinterpreted or maybe we're not giving them messaging, correct that although fertility declines, as you get older, fertility does not go away until you reach menopause. So it is theoretically possible to get pregnant up until that point. It's not likely, but if you wanna be certain, then you need to use some contraception. So again, all although older women, um, do have like more pregnancies when they're older, they're also having more surprise pregnancies as well compared to younger women.

Dr. Nicole (10:06): So let's talk about issues that can happen in pregnancy and we'll start off with early pregnancy issues. So we know that older women will experience an increased rate of miscarriage compared to younger women. And that is largely due to the decline in egg quality. Whereas men are constantly regenerating sperm. Women are born with all of the eggs that we're going to have and the quality of those eggs declines as we get older and it increases the chances of having chromosome problems. So most of the miscarriages that happen in older women occur in the first trimester, but there is definitely an increased rate of miscarriage. In looking at a couple of studies with the numbers, in one study in Norway, the MIS the risk of miscarriage was lowest in women between 25 to 29. It was about 10%. And then it rose after the age of 30.

Dr. Nicole (11:10): And then for women 45 and older, it was as high as. 53% in another study that looked at almost 150,000 pregnancies conceived by, um, assisted reproductive technology. This one showed that there is an increased risk of miscarriage, even if you see a heartbeat on ultrasound. So for example, in this particular study, um, if a heartbeat was seen at ultrasound, the risk of miscarriage for women less than 33 years old was 9.9%, 33 to 34 miscarriage was 11.4%, 35 to 37 it was 13.7%, 38 to 40 it was 19.8%, 41 to 42 29.9%, and greater than 42 years, 36.6%. So you can see that spectrum, how it increases, whereas the risk for less than 33 in that particular study was about 10%. It was doubled 20%. Once you, you get to around age 40. Now, most of those miscarriages are again, related to chromosome abnormalities. The most common chromosome abnormality is a trisomy where you have an extra, uh, chromosome, typically it's 21, but it can be other ones.

Dr. Nicole (12:33): So, um, and, and they're, I'm not gonna get into the details of like, which of those diseases are compatible with life or issues or things like that. But in general, the most common chromosome abnormality is having an extra, uh, chromosome. So when we look at some of those numbers and I'm gonna give them to you based on data from a second trimester amniocentesis, and then data based on live births, those numbers are going to be different because you're going to have a subset of folks who, if they have a diagnosis at a second trimester amniocentesis, they are going to elect to end the pregnancy. Also some of the pregnancies are gonna end in still birth. So the data from live births is gonna be a bit different than what you have data from second trimester. So for all chromosome abnormalities, for someone who is 35, the risk of a chromosome abnormality is one in 132.

Dr. Nicole (13:33): The risk for trisomy 21, the most common, the risk is one in 250. So that is at age 35. When we look at live births, the data, the risk for any chromosome abnormality at age 35 is one in 204. And the risk for trisomy 18, I'm sorry, trisomy 21 is one in 385. Okay. That risk is going to increase. So it increases a little bit, a little bit, a little bit with age with each year in age. So when you get to age 40, the risk of any chromosome abnormality from a second trimester amniocentesis is one in 40. Um, the risk of trisomy 21 is one in 69 in second trimester. At birth the risk is one in 63 for any chromosome abnormality, and then one in 106 for trisomy, um, 21. And when you get to age 45, then it's, um, definitely a lot higher second trimester, any chromosome problem, one in 12, trisomy twenty one, one in 19 for live births, any chromosome abnormality at age 45, 1 in 19 trisomy 21, 1 in 30.

Dr. Nicole (14:46): So it's really a spectrum. The older you get the higher, the chances of having a chromosome abnormality. Now, in addition to having a chromosome abnormality, there is also an increased risk of having a child with what is called a congenital anomaly. So that that's something that's physically, uh, wrong with the child. For example, my first daughter, I wasn't advanced maternal age when she was born, but she had a congenital anomaly called duodenal atresia, but her chromosomes were fine. Her intestines weren't connected together. There is a particular increased risk in older, um, moms of increasing maternal age of having a congenital anomaly of cardiac problems in, uh, one study, the risk of major congenital anomalies for women who were less than 35 was 1.7%, in the ages of 35 to 39 it was 2.8%, and greater than 40 it was 2.9%. And then another study looking at folks, just in Texas, um, babies of women who were 20 to 24 had congenital malformation rates of 3.5%. And then for those 35 to 39, it was 4.4% and greater than 45%. And in both of these studies, cardiac anomalies were, um, definitely increased in both now, as you can hear, the overall numbers are still low. So the risk of having a problem is low. It's just that it is higher as you get older.

Dr. Nicole (16:22): Okay. So let's talk about later pregnancy issues. So some issues that happen in older women are related to just being older, but it can also be difficult to tease out because older women are more likely to have other factors at the same time that can increase the risk of pregnancy complications. For example, having twins or more from having gone through IVF or some sort of assisted reproductive technology, they are more likely to have had children before and having the more children you have, the increased risk that can occur with each pregnancy. They're more likely to have chronic medical conditions, especially diabetes and hypertension. I'm gonna talk about those two in, in, um, uh, in particular, in just a moment. And all of those things are more likely to be present in older women compared to younger women. And that may increase some of the risks.

Dr. Nicole (17:19): So take all of the things that I'm saying with that kind of grain of salt, that it's hard to sometimes tease out the different things. A lot of the studies try to do that, but sometimes it can be challenging. Now with that being said, when you look overall at kind of the data based on the prevalence of issues in older women, such as heart problems, kidney problems, autoimmune problems, obesity, all of those are increased with advancing age. And because of that, overall, the, the data shows that women greater than equal to 35 can expect to experience two to three, fold, two to three fold, higher rates of hospitalization, cesarean birth and pregnancy related complications than their younger, um, counterparts. And if smoking is added, then that's going to increase it even more. Now, I don't want that to frighten you and, you know, make you think, oh my God. And I literally said like 35 isn't a magic number. We do have to like, kind of decide some things in terms of, of, of determining risk. So I just want you to look at that as a big picture, kinda yes, you, you can expect to be an increased risk for some things, but as you will hear the risk overall, the absolute risk is still low.

Dr. Nicole (18:40): Okay. So let's talk specifically about hypertension, both preexisting hypertension and hypertension that develops during pregnancy and diabetes, both diabetes that exist before pregnancy and gestational diabetes that develop during pregnancy, both of those conditions are increased in over older women. And they are, um, especially increased in older women who are overweight. When we look at hypertension, hypertension is the most common medical problem that is encountered in pregnancy. And it is fairly prevalent in older women. The odds of being diagnosed with chronic hypertension are two to fourfold higher in women who are greater than 35 years of age, compared to women who are 30 to 34. And the incidence of preeclampsia is also higher. The incidence of preeclampsia and the general obstetric population when you put everyone together is about three to 4%. This increases to five to 10% in women over age 40, and it's as high as 35% in women over age 50, I'm gonna be honest.

Dr. Nicole (19:42): Y'all I'm 47 knocking on 48. I cannot imagine being pregnant over age 50. That's just a random side note. Okay. Um, I will say that the maternal and fetal issues that can be related to hypertensive disorders in pregnancy can certainly be reduced with monitoring, appropriate interventions most often, which is gonna be induction, but there is an increased risk of pre-term birth, having smaller babies and also Cesarean birth. And I want you to hear that those numbers were still low. So it's like a three to 4% up to 10%. So still not likely it's just a higher chance.

Dr. Nicole (20:23): Okay. And before I move on to diabetes, let me say, I'm not throwing shade to anyone who is pregnant older, more power to you. I just know that for me and where I am in my life right now, I certainly couldn't imagine being pregnant, um, in right now or in my late fifties. Okay. All right. So let's talk about diabetes. The prevalence of diabetes increases with maternal age, both the rate of having diabetes before pregnancy and gestational diabetes. Those are increased anywhere from three to sixfold in women 40 years of age or older, compared with women who are age 20 to 29. When we look at the incidence of gestational diabetes in the general OB population, it's about 3%. That's going to rise to seven to 12% in women over age 40, and then 20% in women over age 50. So again, the overall risk is low, but it is most certainly higher.

Dr. Nicole (21:18): And having preexisting diabetes in particular is gonna increase the risk of congenital anomalies. It's gonna increase the risk of stillbirth. It's going to increase the risk of having a big baby with gestational diabetes. So oftentimes there are different things that are working together like age plus diabetes, plus hypertension plus weight can all kind of work together to increase risk, and it can be hard to tease out what those, those exact risk are based on each factor. But I just wanna give you a good overview of all of the information that we have out there. Okay. So let's talk about placenta issues, women who are over the age of 40 and having their first baby have a tenfold increased risk of placenta previa. Placenta previa is an issue where the placenta covers the opening of the cervix, but the absolute number is low for women who are 20 to 29. The risk of placenta previa is 0.03%. Whereas for women greater than 40, the risk is 0.25%. So overall, very low, but there is an increased risk. Interestingly, there doesn't seem to be an increased risk of placenta abruption. I had in my mind that that was an increased risk, but placenta abruption by itself. And like in the absence of other issues like hypertension or diabetes is not increased in older women, if you don't otherwise have any issues.

Dr. Nicole (22:44): Okay. When we look at low birth weight and preterm delivery, advanced maternal age in the majority of studies, um, shows that it is in increases the risk of both. So the older you are, you have an increased risk of low birth weight and preterm delivery. I try to focus data on studies from the United States because you can't always use data from other countries in order to apply it to us. We do sometimes because that's the best data available, but I really in the podcast, try to focus on giving you the data from studies in the US. And in one study, the adjusted odds ratio for delivering a low birth weight infant increased with each five year increase in maternal age. So, um, it was 2.3 times for women who were greater than 40 compared to women who were 20 to 24. Interestingly, in that, in that study, the maternal age effect on having both a very low birth weight and preterm birth was similar for the oldest compared to the youngest group.

Dr. Nicole (23:46): So in that particular study, it showed a increase risk for low birth weight. In other studies in Sweden and Canada, they have shown an increased rate of preterm delivery rates in older women as well. But again, that, that data is from folks outside of the US. There is one Finish study and it was a big Finish study of about 125,000 folks that actually did not show an association. So that's why I say most studies do. Um, but there is at least one study that doesn't. So I did wanna make you aware of that, but the data we have from the US does show a slightly increased risk of preterm birth and low birth weight. Now let's talk about still birth. This is probably one of the biggest things that, uh, we all get scared about is stillbirth in older, uh, maternal age folks. And that is because the older you get, as I said, the difficulty with getting pregnant increases.

Dr. Nicole (24:41): So it's harder to get pregnant as you get older. And I hate to sound like I, like, I don't wanna sound like callous and say like, you know, someone who's 25 has like lots more years to try and have another baby if they're pregnant. So a stillbirth then is not as, as difficult per se, obviously stillbirth at any point in pregnancy is incredibly difficult. But the reality is that a 25 year old, who has a stillbirth has 10, 15 years to try to have more children, whereas a 40 year old who has a stillbirth does not have those same number of options available. I do think that in our society, we have not always done a good job of explaining that fertility really honest to God does decrease as you get older, please do not ignore that. Cuz you will be unpleasantly surprised if you run into issues and wait too late to get pregnant.

Dr. Nicole (25:43): Um, when you see, and I'm going off on a little bit of a tangent here, but when you see celebrities and things who are getting pregnant in their late forties and fifties, that is often or likely due to the use of a donor egg, um, not their own eggs or if it's using their own eggs, they've had to go through many, many, many, many rounds to get there. Typically like some fertility clinics won't even use a, a woman's own eggs over certain age because of the, the quality is so low. So it is a reality that fertility decreases as you get older. So that's why we get really concerned about stillbirth and advanced maternal age.

Dr. Nicole (26:19): Now with that being said, let me tell you what the numbers are because they do go up. Okay. So in one study of over 5 million Singleton pregnancies in the US, the risk at the risk of stillbirth at 37 to 41 weeks for first time moms increased significantly with maternal age. So the risk of stillbirth for women under the age of 35 in this study was 3.73 per 1000 pregnancies between 35 and 39. It was 6.41 per 1000 pregnancies. And over 40, it was 8.65 per 1000 pregnancies. Okay. So it doubles between under 35 and over 40. Still the overall risk is low, but it, it certainly goes up and it definitely increases at 40 weeks for older women. And that's gonna come into play in a minute 40 weeks for older women. Whereas for younger women, the risk of still birth tends to increase more so over 41 weeks.

Dr. Nicole (27:27): So for older women, the risk sharply increases at 40 weeks, for younger women, 41 weeks. And I'll talk about why that's important in a minute. In another study, the numbers were similar, it was six per 1000 pregnancies, still birth among all pregnant folks. And when you looked in older women, it was 10 still births per 1000 births for women aged 40 to 44 and 13.8 per 1000 births in women older than age 45. And that was even taken to account things like hypertension and diabetes. And then, and yet another study using national center for health statistics, data that's from the CDC. This was about 5.5 million Singleton pregnancies without any congenital anomalies. Um, uh, that study found that the risk of stillbirth was threefold higher, higher for those aged 40 and older compared to those with, um, who were younger than 35. So yes, data very strongly supports that the increased risk of stillbirth goes up with age, but the overall risk or the absolute risk I should say is still low, but it definitely goes up with age now, interestingly, in contrast to the increased risk of stillbirth with increased maternal age, the risk of neonatal death among babies who are born preterm is lower in preterm infants of older women than it is in younger women.

Dr. Nicole (29:02): And they think that they may just be to, um, women having higher getting steroids and maybe lower rates of things like substance abuse, but babies of, um, moms who are born early and the mom is older, tend to do better actually than women who are younger.

Dr. Nicole (29:25): All right. So let's talk about labor and cesarean birth. So studies show that women who are greater than 35 do tend to have a slower labor and they have a higher risk of being delivered by cesarean, but there are some caveats with that. Okay. It's a little bit controversial. Some of it is because of an increased risk of medical issues that will cause, um, um, cesarean birth to be needed for the health of the mom or the baby. There is an increased risk of breach presentation as women gets older. So that contributes to it a little bit, but there is also probably a lower threshold to move to cesarean birth on the part of physicians, for sure. And there is maybe a lower threshold among patients as well. It is not uncommon that we see in older women that they're like, Hey, this is my one child.

Dr. Nicole (30:28): I just, you know, let's just get this done and have a cesarean birth or even cesarean birth on maternal request, which is, you know, totally reasonable, a whole nother topic. So, um, there are lots of reasons why there's an increased risk of cesarean birth in women who are older. Um, I don't think it's necessarily related to any issues with labor and certainly plenty of women who are over 35 have vaginal births. Um, but you do need to know those caveats so you can be informed and make the best decisions for yourself. Okay. So the final couple things I wanna talk about are, um, maternal morbidity and mortality, and then a couple other just random things thrown in. Actually let talk about the couple random things then I'll end with maternal morbidity and mortality. So advanced maternal age is associated with the increased risk of twins and that's largely reduced largely due to the increased, um, use of assisted reproductive technology.

Dr. Nicole (31:26): But interestingly, the outcomes of multiple pregnancies in older women are as good or better than the outcomes in younger women. I, we don't know why that's the case. So it's very different, a single pregnancy versus multiple pregnancies. And then the other thing that we know is a short inter pregnancy interval, especially in women who are over, um, 35, so pregnancies, uh, between birth and then getting pregnant again, that is six months or less. If that that's a short interval, if it's less than six months, that definitely increases the risk of having complications. Okay. So to end with maternal morbidity and mortality, um, 100% women who are older, have an increased risk of issues if they, um, happen in pregnancy. So in one study from Washington State, this was over 800,000 Singleton births in women who were age 40, they had an eightfold increased risk of amniotic fluid embolism.

Dr. Nicole (32:24): That's something that's rare. And then a threefold increased risk of shock compared to women who were 25 to 29. Um, women who were in the 45 to 49 age group had a 16 fold, increased risk of kidney failure, a fivefold increased risk of admission to the intensive care unit. When the groups were stratified by age, compared with women who were 25 to 29, the risk was 0.9% for women who were 40 to 44. So low. 1.6% for women who were 45 to 49, uh, and then 6.4% for women who were 50 or older, that was the risk of having any, any issues. And in this particular study, they adjusted for things like education, race, marriage status, insurance, all of those types of things. And then in another study of about 37 million deliveries, it showed that women between ages 45 to 54 had a 3.5 times risk of severe maternal morbidity compared with women age 25 to 29.

Dr. Nicole (33:37): Okay. Also the risk of cesarean birth, preeclampsia, postpartum hemorrhage, gestational diabetes were increased as well. So I say all that to say that the risk again, does increase as you get older. Although the absolute chances of anything happening are actually low, okay. Are actually low. All right. So taking all of those things into account, how do we manage pregnancy in women who have advanced maternal age? So in the early part of pregnancy, it's actually not much different. So you may be tested earlier for just, uh, for type two diabetes, meaning diabetes that existed before pregnancy, just because oftentimes women may not go to care other than their OB GYN or other than when they're pregnant. Um, so we may test for diabetes early in pregnancy in the first trimester, uh, as opposed to the third trimester where we typically test for gestational diabetes, we may test in the first trimester, but then otherwise everything is pretty much the same.

Dr. Nicole (34:49): You still get offered genetic testing, you still get a comprehensive ultrasound around 20 weeks to look for everything. So not much is generally different. Okay. Um, there is also a recommendation for low dose aspirin for reduction of preeclampsia risk for folks who are age 35 and older, that is an increased, uh, that does put you at increased risk for preeclampsia. So if you are 35 and older and have at least one other risk factor, so another risk factor would be obesity, hypertension, diabetes, previous history of preeclampsia. Um, you should be on a low dose aspirin. That is one of the things that has actually been proven to help reduce the risk of preeclampsia. So that's considered a really strong recommendation from ACOG. And I will say that I'm, that the things that I'm talking about are from ACOG, the American College of Obstetricians and Gynecologists, their recommendations for pregnancy care in women 35 and older, you will find that practice and practice.

Dr. Nicole (35:51): Some things are done different, but when I'm telling you are the recommendations from ACOG. So, um, early pregnancy care, pretty much similar, you may be on a low dose aspirin, but not much different. Okay. So things are a little bit different as you get towards the end of pregnancy. So because of the risk of large progestational age and small for gestational age babies, so babies who are larger than we suspect based on how far they along they are when they're born or smaller, ACOG does suggest an ultrasound for growth in the third trimester, for those who have an anticipated delivery at age 40 years or older, okay. 40 years or older. Now I will say that ACOG grades that recommendation as weak and based on low quality evidence. All right, so it's weak and based on low quality evidence. And a lot of that is probably because third trimester ultrasound for growth can be notoriously inaccurate.

Dr. Nicole (36:52): So that is one of the reasons, but there is some data that shows that as women get older, babies may be bigger or smaller. So for example, for macrosomia, the rate of macrosomia is about 12% in women younger than age 35, 12.6% in women age 35 to 39, and then 15.4% in women age 40 years or older. So not a huge increase, but an increase in the, the differential is similar for small, for gestational age babies as well. And so based on that limited data, that is where ACOG makes that recommendation. Now they do have a couple of caveats to that. One is that although, um, the data demonstrates increased risk of growth in babies that are women aged 40 and older, they do very specifically say that there is insufficient evidence to recommend ultrasound for growth in the third trimester for women who are 35 to 39, unless they have other risk factors.

Dr. Nicole (37:58): So it really is specifically for those who are 40 and older, and there are no guidelines regarding the timing of when it's done in the third trimester or the frequency of when the ultrasound is done for women who are greater than 40. So this is where you will see a lot of variation in practice. You'll have one doctor who may say, oh, you're gonna get an ultrasound at 32 weeks and 36 weeks for growth. We'll, we'll kind of follow it and see, um, we do have some doctors who will do that for women who are greater than 35, even though ACOG says it should really be 40. Some other sources may say 35. So there's just gonna be a lot of variation potentially in care. There's not a lot of good data to form recommendations about this. All right, now, next ACOG says that they suggest offering what's called antinatal fetal fetal surveillance for pregnant individuals with an anticipated delivery at age 40 years or older, given the increased risk of still birth.

Dr. Nicole (39:01): So I talked about the increased risk of still birth, particularly for 40 and old older. So that is why they, they suggest offering antinatal surveillance. They called this also a weak recommendation based on what is considered moderate quality evidence. And that is because the benefits of it are really unknown. There aren't enough large studies. We it's very difficult to study interventions like this, especially for stillbirth, cuz it's gonna be like, okay, we need like 10,000 women who are 40 to decide that they will be in the study. 5,000 of y'all will say, Hey, we're not gonna look and do anything. The other 5,000 will say, Hey, we will do something. And then just kind of see what happens. Like that's a really hard study to do. Uh, so it's, it's, it's probably something that's never going to happen. Um, studies of things in pregnancy can be challenging for, for that very reason with that being said, however, ACOG, and also the society for maternal fetal medicine have kind of set their own recommendations and guidelines that if the risk of stillbirth is more than 0.8 per 1000 and that's based on, um, some other data, I'm not gonna go into that.

Dr. Nicole (40:17): But if the risk of stillbirth is greater than that, then they recommend doing what's called antinatal surveillance and antinatal surveillance can be doing NSTs, non-stress tests. It can be biophysical profiles, which is looking at the baby on ultrasound as well. And so they say that because of that data supports offering antinatal surveillance for pregnant folks who are anticipated to deliver at age 40 or older, they do specifically say for individuals, age 35 to 39, there is insufficient evidence to recommend it in the absence of other risk factors for stillbirth. Okay. I like hypertension. I know I go back to that a lot, but that's pretty common. And they also say that there is no recommendation for the timing and frequency of antinatal surveillance. So when does it start, does it start at 35 weeks does it start at 36 weeks, there are no specific recommendations. So that is going to be doctor dependent.

Dr. Nicole (41:17): Okay. And then the question that I get the most induction about, uh, for those who are quote unquote advanced maternal age ACOG says we recommend proceeding with delivery in well dated pregnancies at 39 weeks, zero days to 39 weeks and six days for individuals with anticipated delivery at age 40 years or older due to increasing rates of neonatal morbility and stillbirth beyond this gestational age. All right. So I talked about that earlier that especially over 40, the risk of stillbirth goes up. All right. But what I also want you to know is that it doesn't seem that induction increases the risk of cesarean birth in this, in this particular cohort. So there was one randomized trial that specifically evaluated the effect of induction of labor compared with waiting on the rate of cesarean birth in women aged 35 years and older, it included 600 women.

Dr. Nicole (42:28): They were randomized and randomizing is the strongest level of scientific evidence that we have. They were randomized to either labor induction between 39 weeks and 39 weeks and six days or expected management up to 42 weeks in this particular study, it was in 2016. I believe they did not have any anti-natal surveillance unless there was a other reason to do so. So no NST, no biophysical pro profiles. And in this study, there was no difference in the groups in the cesarean birth rate. 32% cesarean birth rate in induction of labor group, 33% cesarean birth rate in the expectant management group. And people can look at this difference. Some people will say, oh, there's no difference than you might as well be induced. Uh, some people will say, oh, there's no difference. So you might as well wait, it's really how you interpret the data. There was also no difference, intrapartum postpartum complications or neonatal outcomes such as still birth or NICU admissions.

Dr. Nicole (43:30): So in this particular study, it said that both options were reasonable. The arrive trial, which is a study that is quoted a lot in terms of labor induction in a subgroup analysis of women aged 35 and older compared to those who were younger than 35, there actually was no difference for the primary outcome of issues with baby or cesarean birth rate. So there was no difference in cesarean birth rate for those who were greater than 35 when you were induced verse not induced. So in this particular, um, case, it does not increase the chances of cesarean birth. Okay, but it will decrease the risk of still birth. So this is really a shared decision making process about the things that are important to you. And this goes back to remember how I said the rate of still birth at 39 weeks, um, goes up a lot for women who are older compared to it's similar to the rate for women who are beyond 41 weeks.

Dr. Nicole (44:32): So the rate of stillbirth roughly at 39 weeks in women who are aged 40 and older is about the same as the rate of stillbirth for women who are aged 25 to 29 and who are beyond 41 weeks. So in general we say induction after 41 weeks to reduce the risk of stillbirth, but that, and that's based on a specific data or number, but that rate is the same as for 39 weeks. So that's where we get that. We don't want you to go. You know, we, we, I, I shouldn't say we don't want you to go, but we often suggest 39 to 40 weeks, especially for women over 40 should definitely be considered or offered knowing that you don't have many opportunities to get pregnant again. And the chances of a successful induction are likely, and it's not likely to result in a C-section as long as you have a doctor who is, will go the distance for, for the induction.

Dr. Nicole (45:33): Now that was all for women who are 40 and over ACOG specifically says that between 35 and 39, the evidence for elevated stillbirth risk is not sufficient to support a clear recommendation regarding timing of delivery beyond routine practice. So for stillbirth, between 35 and 39, the data is, is not there. Okay. And then the final thing that I will say is that ACOG suggests counseling, that vaginal birth is safe and appropriate. If there are no other maternal or fetal indications for cesarean birth, a lot of times you'll hear people say, oh, because you're older, you're just, you know, you should just go ahead and have a cesarean. That is not true. That is not what the data says. ACOG says, there's no reason why you cannot go for a vaginal birth. Um, and that is considered a strong recommendation. Okay. So don't let anyone say that because of your age, you should just have a C-section.

Dr. Nicole (46:27): That is not what ACOG says. All right. And then the final things that I will say, and these are just a couple little bonus things are some of the things or data for later in life, for those who are older parents. So one study noted that increasing maternal age was associated with improved health and development for children. Up to five years of age, they have less unintentional unintentional injuries. They have better language development, social development. Um, they also often have like more, the parents are more patient. Um, they have the attention of their parents. There's more financial stability. So there are some benefits to waiting until you're older to have children.

Dr. Nicole (47:16): Now you do have to be aware of things like being mistaken as grandparents or the possibility that because of your age, you have a higher risk of serious illness. So you have to get things in place to be able to provide support for your child like insurance and life insurance and all of those kinds of things. But there certainly are some, some benefits to, to having children at an older age. Okay. So as we wrap up, here's just a recap of the episode. Number one, advanced maternal age is not strictly defined. 35 is not a magic number. It's arbitrary. It's really a spectrum. The risk related to pregnancy increase with, with age and those risk especially increased over the age of 40. They can also be influenced by other factors like hypertension, diabetes, or weight issues during pregnancy as well. With that being said, pregnancy complications do increase with age, including miscarriage, chromosome problems, some con congenital issues, especially cardiac problems, placenta previa, gestational diabetes, preeclampsia, cesarean birth.

Dr. Nicole (48:28): There may be an increased risk of pre-term birth. There's also an increased risk of stillbirth. The over the absolute risk of those things happening is low, but the risk is increased. Pregnancy care actually is not drastically different, especially in the first and second trimester just based on your age. However, the third trimester is may vary depending on the doctor. ACOG says offer ultrasound in third trimester. Although the timing and frequency is not established, and those that's for pregnant women who are 40 and older also offer labor induction for those who are 40 and over and keep in mind that labor induction will not result in an increased risk of cesarean based on the studies that we have. And as long as your doctor will go, the distance with induction, because sometimes it can be a long process between 35 and 39 that is not as well established, even though a lot of doctors will push for that.

Dr. Nicole (49:23): You can tell them that ACOG does not recommend that, um, that is, but they say in their document, it's not necessary between 35 to 39 just based on age alone. Okay. Remember, there may be other factors that, um, influence the decision or the discussion regarding induction. Okay. And then the final thing is just remember that still, even as you get older, although the risk are increased, the most likely thing is that things will be fine, but you need this information so that you are prepared just in case. And then last thing do not forget to get educated comprehensively about childbirth, and you can do that through childbirth education, do check out the Birth Preparation Course my signature online childbirth education class that will get you calm, confident, and empowered to have a beautiful birth, get all the details at drnicolerankins.com/enroll. One of the benefits of the course is the private Facebook group.

Dr. Nicole (50:21): And there's a community in there of lots of different types of moms, including moms who are advanced maternal age. So that's a great resource for you as well with the course. All right. So there you have it. Share this podcast with a friend, sharing is caring. It helps me to reach and serve more pregnant folks. Also subscribe to the podcast, wherever you're listening to me right now, leave me a review, in Apple Podcast. I'd love to hear what you say about the show and it helps other women find the show. We can connect further after the show on Instagram, you can find me there while I am posting regular content to help you during your pregnancy and birth. I am on Instagram @drnicolerankins. So that's it for this episode do come on back next week and remember that you deserve a beautiful pregnancy and birth.