It’s a common question we hear about fertility. Our chances of becoming pregnant do decrease as we age. After the age of 35, and again after about the age of 40, there’s a significant decrease in a woman’s chance to conceive on her own without any assisted reproduction or infertility help.
We often receive referrals from our OBGYN colleagues and sometimes our infertility colleagues to help prepare a woman to become pregnant and help her optimize her health. If she comes to us because she’s struggling to conceive, we start that conversation, but often refer them to our infertility colleagues and work very closely with them as a woman is seeking various options to achieve pregnancy.
The risks associated with becoming pregnant do depend on age to some degree and also depend on a woman’s underlying health. We characterize potential concerns or risks in a fetal or baby perspective and also from the maternal side, the maternal perspective.
What we often don’t think about is a woman’s underlying health. Cardiovascular disease, gastrointestinal diagnoses, autoimmune conditions, and diabetes or hypertension before pregnancy are all diagnoses that do increase with age and can pose risks to a pregnancy.
With hypertension in particular, a fetus, a baby, may have more difficulty growing. A small pregestational age or a fetal growth restriction situation may arise and warrant further monitoring, further consideration. Those can sometimes lead to a need to deliver a baby earlier than what you would expect to optimize health for both mom and baby.
If you learn you’re pregnant and you are 35 or older, one of the most important things is to see a provider. That could be a physician, a nurse practitioner or a midwife, early on. What you really want to do is plan and prepare.
For many women, they may have planned that pregnancy and already have their provider ready to go.
Unplanned pregnancies are also extremely common and getting in to see someone who’s going to be your prenatal care provider early on is key.
We generally start with an ultrasound. If a woman is referred to our office, the high-risk pregnancy office, we’re seeing them for a detailed ultrasound, ideally between about 11 and 14 weeks. Often women think of this as the NT ultrasound because we’re measuring a small space in the back of the baby’s neck called the nuchal translucency, which in conjunction with other assessments can give us more information about a pregnancy’s risk of being affected by Down syndrome or many other chromosome or developmental differences for that baby. That’s one of the starting points where a high risk doctor like myself will play a role.
Genetic testing comes along with that. There are many options these days for women to seek genetic information about her fetus, many of which are noninvasive. For instance, we can draw maternal blood anytime from about 10 weeks of pregnancy after and assess the risk of that pregnancy being affected by Trisomy 21, or Down syndrome, and a handful of other genetic diagnoses. Notably, those are screening tests and don’t give us all of the information about a baby. But it does give us a starting point for a conversation that may lead to more information if desired or needed.
When a concern is identified on a screening test, we see it as a starting point of the conversation. These are screening tests. They don’t give us all the answers. They often generate a lot of questions that we, along with our partners, our genetic counselors, work closely with the woman, a family, a couple, to seek answers.
The ultrasound plays an important role as well, whether in that early 11 to 14 week time period or later, the ultrasound that people often think of as the anatomy scan. They know they are doing that at five months of pregnancy, or 19 to 20 week period.
When we identify a concern on a screening test, or let’s say a structural concern about fetal development on our detailed ultrasound imaging, we have the opportunity to offer women what we call diagnostic testing.
One of those options is called an amniocentesis, which can be performed at 16 weeks or later in pregnancy. We can learn an enormous amount of detail, both about chromosomes, other genetic diagnoses and much more. The earlier version of that, where we sample the placenta is another diagnostic procedure called a CVS or a chorionic villus sampling. Those are two procedures that only a perinatologist or a maternal fetal medicine physician is trained to do.
Certainly, the early ultrasound and the anatomy ultrasound are important for all women, but let’s say a woman is 35, 37, 40, but otherwise in very good health with no chronic medical conditions, we tend to recommend an assessment of baby’s growth, often around 28 and 34 weeks, but scattered throughout the third trimester to potentially identify lagging growth, new concerns, or even excess growth, such as with a diabetes diagnosis.
There’s some additional testing we do as well. We call it a non-stress test. Women who have had a baby before might remember when they’re in the hospital, in labor, the nurses are paying close attention to the baby’s heartbeat by putting little monitors on the belly. Results print out on a computer screen and it gives us a good assessment of fetal well being. I think of it as one step up from simply listening to the baby’s heartbeat in your doctor’s office. It’s a way of getting a bit more information to hopefully tell us that baby’s doing just fine inside and has no reason to be delivered early.
In general, when you learn you are pregnant, avoid alcohol, smoking, drug use. Also, address your other medications, which ones might be beneficial, which ones are essential. Potentially, there might be a need to change certain medications in discussion with both your regular doctor and a maternal fetal medicine specialist.
Separate from that, we encourage usual activity to the extent that you’re able to do. Often women believe that they must decrease their activity and be on bed rest. In fact, there are very few situations where that is something a physician would recommend. However, if you are overall healthy, listening to your body is key. I often tell women to keep doing what you normally do, but give yourself a break when you need it.
The Scripps perinatology program offers a comprehensive approach to care across the Scripps system. Women of any age, and certainly those 35 or older often see us a few times in pregnancy for those detailed ultrasounds, perhaps a detailed counseling session, where we outline a plan of care that then their physician, their provider, whether a nurse practitioner or a certified nurse midwife across the Scripps system, can enact. Then we’re available for questions, concerns, and to update those recommendations, if any new concerns arise.
For some women, they see us once and then they’re cared for by their obstetricians, their prenatal care providers. Others, we see throughout pregnancy and work closely with their physicians or other providers. For some, we see for their entire prenatal care, if their maternal or fetal needs warrant that.
For women entering our office 35 years of age or older, they’re often walking in with a lot of misconceptions or fear. The role we often play is to hear them, listen to them and do a lot of education because most women 35 or older can and should have a healthy pregnancy. Just because we do some additional testing or additional follow up does not mean those women should expect anything other than a healthy baby. If there is anything we can do to help them achieve that, we will do it.
Lightly edited for clarity.