Advanced maternity Age
As time is passing by, the perspective of women about having children has changed gradually in societies with high sociocultural level. Long-term educational processes and taking part in business life as well as men have gradually delayed the timing of having children. Here, pregnancy ending with abortion is legal in many countries of the world and the success of advanced IVF applications has also played a role. Even the possibility of conceiving with someone else’s egg (ovum donation) is a factor that supports the woman’s hope of late pregnancy and is applied in many countries of the world.
Setting an age restriction for the concept of advanced maternal age is a must for the recommendation and implementation of the examination and treatment protocols. In this sense, the age limit of 35 has been determined and accepted by FIGO (International Federation of Gynecology and Obstetrics). However, this age is being discussed as the age of having children is gradually delayed. However, 35 years of age seems to be the logical option, since overall risks are taken into account. The risks gradually increase towards the figures specified for advanced maternal age and the increase continues after 35 years of age. It is not true that the risks suddenly increase dramatically. Because, as mentioned before, the age limit is envisaged for the establishment of medical measures and practices, diagnosis and treatment models.
In advanced maternal age, the risks of the fetus and the risks of the mother should be evaluated differently. Risks related to the fetus are chromosomal anomalies determined by the deterioration in the mother’s egg structure. It is the most prominent example of trisomy 21, referred to as Down Syndrome. Down Syndrome, which is seen in a 1200-year-old woman in a 20-year-old woman, increases with statistical frequency as 1/900 at 30, 1/350 at 35 and 1/100 at 40. At 44 years of age, the probability is determined as one in 40 pregnancies. In addition to diagnostic tests such as non-invasive double, quadruple screening test and integrated test, non-invasive maternal blood, fetal DNA screening and detailed ultrasonography, invasive diagnostic tests such as amniocentesis, chorion villus biopsy and cordocentesis can be applied in pregnancy follow-up and examinations performed considering these possibilities. These decisions should always be made with the family, explaining the risks in detail.
In this discussion, we will talk about the situations that concern the mother and thus complicate pregnancy. The important thing here is to know the general health of the woman before pregnancy and to examine it if necessary. Because in the presence of chronic diseases that can start at this age, the risks are more pronounced because the disease already exists in the infrastructure. If hypertension, diabetes, cardiovascular diseases, connective tissue diseases, increased cancer probability, and neurological diseases are detected beforehand, a clearer counseling regarding pregnancy will appear and a precautionary measure and follow-up program can be made.
In advanced maternal age, the rate of hypertensive diseases complicating pregnancy increases 2-4 times and hypertension is observed in 10% of pregnancies.
Hypertension that occurs in the late stages of pregnancy is generally related to chronic hypertension of the mother. If necessary, alpha methyl dopa can be used in treatment and it is not expected to affect pregnancy in mild forms. However, if pregnancy-induced hypertension is severe and missed, there will be a need to terminate pregnancy if there is an organ effect such as liver and kidney with protein outflow in urine, and eclampsia develops. Since mother and baby is considered as a life-threatening condition, premature birth should be considered if necessary and pregnancy should be terminated urgently, especially in the case of severe preeclampsia and eclampsia.
The risk of preeclampsia increases with age. The risk of preeclampsia increases only if the mother has chronic hypertension. Chronic hypertension should be investigated for the prediction of this condition in which advanced maternal age does not add any additional risk. Pre-mild preeclampsia frequency is the same in the mother candidate who does not have hypertension disorder at present.
Unlike hypertension, the prevalence of type 2 diabetes on the background of chronic disease and gestational diabetes (pregnancy-related diabetes) increases in advanced maternal pregnancies. In total, 2-3 times increase compared to young pregnancies is valid for both cases. In addition to other risk factors available for diabetes. The increased tendency to obesity in advanced maternal age may also contribute to this frequency.
Advanced mother age; In addition to following fasting blood glucose in the early weeks, it will be very useful to perform glucose loading with 100 g for the second time in 12 weeks and if the load is normal, and to diagnose diabetes as early as possible. In this case, the nutritionist and, if possible, the endocrinologist should get help and it is appropriate to avoid stress with a moderate exercise program.
* Connective tissue diseases, cardiovascular diseases, neurological diseases and increased cancer tendency are other reasons that make maternal pregnancy difficult. Risk factors such as hypertension, diabetes, cardiovascular diseases and obesity, and an increased risk of thromboembolism can also be detected. In all cases, although the approach differs, it is imperative to take dynamic precautions since pregnancy complications will increase significantly in their presence.
Problems encountered in the course of pregnancy
* Chromosome anomalies:
The frequency of numerical chromosomal anomalies (especially Down Syndrome) increases in women with advanced maternal age. The frequency of structural anomalies concerning the organ and body structure remains unchanged with age.
* Growth restriction and large baby in fetus:
The advanced maternal age and the fetus’s weight gain rate may decrease compared to normal age pregnant women. This possibility increases especially when systemic diseases such as hypertension and diabetes are accompanied. However, in the presence of obesity and diabetes, on the contrary, the frequency of large babies also increases.
* Abortion (miscarriage):
The most important cause of abortions are chromosomal anomalies, and since the frequency of chromosome anomalies increases with age, the risk of miscarriage increases 3-4 times over 35 years of age.
* Ectopic pregnancy (extrauterine pregnancy);
Possible pelvic infections with previous age may have affected the tubes or tube movements may be decreasing with age. For these reasons, the risk of ectopic pregnancy in the advanced maternal age increases by 2 times.
* Late pregnancy bleeding
The first of the conditions is the bleeding caused by placental detachment (bleeding behind the placenta and leaving the placenta where it is attached to the uterus). Age does not increase the risk of detachment on its own. However, since the risk of hypertension increases in advanced maternal age, hypertensive process increases the risk of detachment in this group. This frequency is given as 3% (1/200 frequency in normal age range).
The second reason for late bleeding is placenta previa. Placement of the placenta is related to the number of pregnancies, rather than age.
Since the addition of systemic diseases such as hypertension and diabetes in advanced maternal age may require an urgent birth decision that threatens the life of the mother and baby, preterm birth decision is made more frequently than normal age. In addition, advanced maternal age alone increases the likelihood of preterm birth. The risk of preterm delivery seems to be 3-4 times higher than women of normal age.
* Delivery difficulties and the problems with the fetus and newborn:
During advanced maternal labour, contraction and pain can be regulated, the cervix is opened properly, and longer processes and difficulties occur even when the baby is at normal weight. Large baby birth, which may accompany diabetes, triggered by self or obesity, also increases the possibility of non-progressive labour and shoulder attachment.
For these reasons and due to the birth of the mother at an older age, both the mother and the doctor increase the probability of caesarean anxiety about vaginal delivery.
In this context, the possibility of fetal distress due to birth difficulties, neurological sequela due to the lack of oxygen of the baby and unfortunately the possibility of sudden loss of the baby in the womb or during birth are also increased probability compared to normal pregnancies.
* Maternal and infant deaths:
Both the risks added by chronic diseases in the mother and the difficulties of birth increase the probability of maternal deaths as 6 women out of every 10000 women. This corresponds to 4 times the normal age pregnancies. The possibility of infant deaths is around 1.5 times higher than normal age births. These risks have decreased considerably due to the development of medical opportunities, innovations in diagnosis and treatment, and the improvement of maternal and infant intensive care conditions.
* Cost of advanced maternal age:
Compared to normal pregnancies, high-risk follow-up protocols are the first step to increase costs. Among these, the costs of laboratory and doppler ultrasonography required by diseases such as diabetes, hypertension, invasive prenatal diagnosis interventions and genetic laboratory costs, frequent doctor visits, and consultations such as endocrinology. During pregnancy, delivery process and long hospitalization periods that may occur after birth and the need for intensive care for mother or baby increase the costs considerably.