Care of the Older Pregnant Patient Part II

Abstract

More than ever before, obstetricians/gynecologists (OB/ Gyns) today are encountering an increasing number of patients who wish to conceive at an older age. This trend is illustrated by the fact that the total number of live births in women older than 45 years more than doubled from 1996 to 2006. The phenomenon of reproduction at an older age raises numerous medical to ethical issues as practitioners learn how to safely and effectively manage the older pregnant patient. However, data and experience in this area are both relatively sparse, and there is a gap in the education and preparation of many OB/Gyns caring for these patients. The purpose of this lesson is to improve the ability of physicians to effectively address these issues, including preparing a prenatal care plan for this group, identifying the complications unique to this patient population, and discussing the role that advanced paternal age may play. Management of PregnancyOnce conception and ongoing pregnancy have been established, attention turns to managing the pregnant patient. In general, care of the older gravida does not differ significantly from that of the younger patient. However, practitioners must be aware of specific risks attendant to the older patient so as to be prepared in the event that complications arise. Antepartum CareUnless a preexisting medical condition warrants more specialized care, the older pregnant patient should be managed similar to the younger gravida, with the same screening tests, sonograms, and other aspects of routine management. As recommended by American College of Obstetricians and Gynecologists (ACOG), 1 we offer first-trimester aneuploidy screening (measurement of nuchal translucency and biochemical markers) to all patients regardless of age. Any patient with an increased aneuploidy risk based on screening should be offered prenatal diagnosis via chorionic villus sampling (CVS) or amniocentesis. Although the older patient who conceives with autologous oocytes has an increased risk of a fetus with a chromosomal abnormality, even those who have used donor oocytes for conception should be offered prenatal screening and diagnostics.Because CVS is performed earlier in gestation than amniocentesis, results are available faster, allowing for earlier and potentially safer pregnancy termination if a patient chooses this route due to fetal aneuploidy. Over time, pregnancy loss rates due to these 2 procedures have decreased, with one large study 2 estimating the pregnancy loss rate at 1 in 370 for amniocentesis and 1 in 360 for CVS. The procedure-related loss rate from amniocentesis has been determined to be 0.06%