“Why All the Fuss About Advanced Maternal Age?” – with Dr. Stephanie Melka

Dr. Melka joins Healthful Woman to talk about advanced maternal age, or AMA. In this episode, she explains the history of identifying AMA and terms like “elderly pregnancy” or “geriatric pregnancy,” clears up misconceptions about risks, and explains common problems that obstetricians screen for or treat in AMA patients.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. Melka, welcome back to the podcast. How goes it? 

Melka: Hi. Things are good. How are you? 

Dr. Fox: I’m great. Always happy to see you, like I do pretty much every day of the week. But it’s nice to podcast together. And we’re talking about advanced maternal age, or AMA, today. 

Melka: Yes. At my request. 

Dr. Fox: Yeah. So explain. What was the request? 

Melka: So this is something I get from a lot of people, a lot of patients, a lot of friends that say… 

Dr. Fox: Because you’re in that age category. 

Melka: I am. Thanks. 

Dr. Fox: Yeah. 

Melka: A lot of people, they hear all these things about how you can’t get pregnant or, at age 35, suddenly you’re too old to get pregnant. And I have a lot of friends that are in their, you know, 30s, 40s that just ask me, like, what do I think about it? 

Dr. Fox: It’s unfortunate because you’ll also hear things, you know, like, elderly pregnancy or geriatric pregnancy. And it’s, like, “Oh, my God.” It’s like that’s a big move to tell someone, at 35, that’s a geriatric pregnancy. So we don’t do that. It’s unkind. 

Melka: It is on the Sano coding sheet, though, in the problem list. The… 

Dr. Fox: Elderly. 

Melka: Yes. 

Dr. Fox: Yeah, the term elderly is on it because that’s part of how the national codes list for pregnant women over 35. They write “elderly,” and it’s… 

Melka: I was gonna say, that’s how you know a man wrote those codes because a woman would not write “elderly.” 

Dr. Fox: I absolutely agree. It’s unfortunate. And it definitely is, it appears to be unkind. But the interesting thing is we don’t really even think about it so much that way. Because, again, like, if you think of, you know, women who are 35, like, walking the planet, no one thinks of them as old. Thirty-five is young, right? You’re young. Like, if you went to a medical doctor, they would say you’re young and healthy, which is true. I mean, if you’re healthy. But they would say you’re young and healthy. But the reason it sort of came up in pregnancy is that, typically, historically, the range of women who were pregnant was, let’s say, late teens to 40s, or early 40s, maybe. So 35 to, sort of, you know, early, mid-40s. Again, this is a nature without use of fertility treatments or anything like that. 

They were the older side of the pregnant group, and everyone knew that they weren’t old in life or, you know, older in life. It’s just related to pregnancy. And the term actually got invented only related to Down syndrome screening. It’s been known, you know, for 100 years, 100-plus years ever since, you know, Down syndrome was first, you know, identified and given a name and, sort of, discovered, and later there was genetic and all this, that it was known that as women get older, the risk of Down syndrome increases. And, you know, we had a podcast about this and all that. And so what happened was, initially, there was no screening test for Down syndrome. And so they just had to decide, “Who are we going to do an amniocentesis on?” That was it. It’s either you do an amnio or you don’t do an amnio. That’s all that was available. 

And the thought was, “Well, what’s the risk of an amnio?” And at the time, this is, you know, in the ’70s, they said, “Well, the risk of an amnio is 1 in 200.” So they said, “Okay, at what point in life is the risk of Down syndrome to 1 in 200?” That was 35. Meaning if you’re younger than 35, the risk of Down syndrome was lower than 1 in 200. So if you did an amnio, it was higher risk than having a baby with Down syndrome. And if you’re over 35, the risk of Down syndrome was higher. So if you did an amnio, that was the lower risk of the two. So it’s really just a line in the sand. And that’s where the term “advanced maternal age” came from. And nothing to do with better health or physiology, how she’s going to handle pregnancy. It was just how do we decide who does and doesn’t get recommended an amnio? 

And that’s sort of fallen by the wayside anyways because of all the Down syndrome screening. But the term has persisted, much to people’s chagrin. And in our counting, a lot of people come into pregnancy thinking, “Oh, the problem is because of genetic and Down syndrome and whatnot.” And then we explain to them, “Well, you know, we have different screening tests now. And it’s not the same way. We don’t just do amnios. We have all these options.” And they say, “Well, then I’m fine, right?” And then we say, “Well, maybe not.” So what else is there about a woman’s age that affects, potentially, her pregnancy? 

Melka: Sort of general risks of different complications in pregnancy increase with age. So more likely to develop preeclampsia, more likely to develop diabetes, higher risk of C-section the older a woman is. 

Dr. Fox: That is something that, amazingly, even though the term is so prevalent…since it’s prevalent for the wrong reasons, right, because it’s not so much a genetic issue anymore in the age of screening, people don’t realize that, actually, there is something to maternal age for all the other outcomes in pregnancy. And so we do, sort of, flip a route. We, sort of, tell people, “No, your age is, like, not a concern to us in terms of genetics because we can screen for that. We can do all those things.” And we counsel people, whether they’re 25, 35, or 45 the same way with genetic, sort of, concerns. But a 25, 35, and 45-year-old have much different rates of adverse outcomes in pregnancy. And we definitely talk about that in relation to what we’re going to do and what they should expect and maybe what tests we’re going to do and what treatments we’re going to do. Do you find that your patients are surprised by this to learn? 

Melka: Yes. 

Dr. Fox: Yeah. In what way, that they just realize, “What’s the deal? Like, I’m healthy”? 

Melka: Yeah. Well, they’re sort of told, “You’re over 35. So you need a high risk doctor.” And they just sort of say, “Okay,” and then they come to us, and they’re like, “Okay, what does that mean?” And they, like, almost see themselves as like a ticking time bomb where they’re like, “I’m old. I don’t know that I should be doing this.” Or, “Am I too old to do this?” 

Dr. Fox: Right. And so when you see someone who, you know, you don’t know already, she’s coming to you the first time…let’s say, hypothetical, she’s 38 years old. She’s coming to you for her first pregnancy, or before her first pregnancy, and she was told that she has to see, you know, you or one of us for this particular reason, just because she’s over 35. How do you talk to her about that? 

Melka: You know, I sort of go over what we started with, that it all sort of comes from…like, it started with the genetic risk, but there’s all these other issues that come into play. And then go over the risk of genetic abnormalities with age, and then the potential impacts on the pregnancy, like the different things that could develop. And some people hear that and they’re like, “Well, if any of that did happen, I would want to be in this group. So I’m gonna stay.” And then others are like, “Oh, that’s nothing. Okay.” 

Dr. Fox: Yeah. “I’m going back to Jersey,” or whatever. It is interesting, because what I tell women is, most women, if they’re pregnant, no matter what their age is, they’re most likely going to do fine. 

Melka: Yes. 

Dr. Fox: Right? And even if they develop one of these complications we’re talking about, with the exception of stillbirth, obviously, which we’ll talk about, you know, like preeclampsia or gestational diabetes, even if they develop it, it’s not likely to be a game changer in terms of their long-term health or their baby’s long-term health. It could be, and so we have to watch for it and take care of it. But, statistically, they’re likely to do fine. And the other predictor that’s so critical is, what is their overall health? Meaning if someone is 33 years old, so she’s “young,” but she has obesity and high blood pressure and diabetes, and she smokes, and she doesn’t exercise, her risk profile is going to be much higher than someone who is 43 who has none of those conditions. And so age is one of the factors we look at, but it clearly isn’t the only one. And it’s not the most important one, either. It’s just one of them, right? 

You’re much better off being, you know, slightly older, without, let’s say, high blood pressure than being slightly younger with high blood pressure. For example, we talk about this in context of her overall health picture, which is, you know, why we have to really evaluate her history and, you know, do an exam and, you know, check her blood pressure, maybe some blood tests and figure all that out before we can give her a sense of, you know, how concerned should she be about as she gets pregnant? We had a podcast with Karen Bleier who was telling, sort of, her side of the equation is pregnancy over 40. And so we covered some of this. What we’re going to talk about is a little more on the medical side. So let’s talk about the risks that are related to age that we go through, sort of, one at a time, either in our heads or with the patient if it’s specific to her. And the first is related to early pregnancy, like fertility and miscarriage. So how do you counsel women about those two in particular? 

Melka: Generally, the older we get, the harder it is to get pregnant. And it’s somewhat related to fertility as well as abnormal pregnancies that ended up miscarrying pretty early on. 

Dr. Fox: Right. And that is the one thing where age is the biggest one. 

Melka: Yeah. 

Dr. Fox: Right? And it’s very hard to circumvent that. Other than, again, if you had some other medical problem affecting fertility or miscarriage, fine, but that’s the exception. Generally, it’s just a function of age. This is how, unfortunately, biology works, how the ovaries are developed and that’s just sort of, the numbers, and this is the reason, frequently, people, as they get older, might need to turn to fertility treatments to get pregnant or potentially to not miscarry, because, again, just the odds aren’t as good. So that’s the one thing when women ask me about, you know, “Should I wait? Should I not wait?” All these things about age. The one thing that, sort of, we can’t “fix” is fertility and miscarriage risk based on age. Again, unless you jump to, you know, infertility treatments, egg donation… 

Melka: [crosstalk 00:09:46], yes. 

Dr. Fox: …like, all these things that can do that, but that’s a big deal, obviously. And so when, you know, there’s this discussion about delayed childbearing, which is much more common now. The average age of women’s first pregnancy is later now than it was 10, 20 years ago. That’s fine. Obviously, it’s anyone’s choice when they want to get pregnant. But that’s the one thing they really need to consider, you know, “How big of a family do I want to have? What would happen if I had a difficult time to get pregnant?” And that something has to be considered much more so than, “Oh, if I wait, I have a higher risk of preeclampsia.” And that’s really…it’s almost never the issue that we’re talking about. 

We spoke about chromosomal abnormalities. Again, that’s something we can screen for. It is a higher risk. But practically it ends up being an issue with miscarriage, not so much at 12 weeks when we do, like, the screens, because we have good tests for that. And so it’s not something that’s going to go unrecognized. I think one thing that we see that people don’t realize is placenta abnormalities is more common. So what kind of things are we talking about? 

Melka: So the location where the pregnancy implants. So higher likelihood of a placenta previa, placenta attaches on top of the cervix, or issues later in the pregnancy with either the placenta not functioning, ideally, and you have growth restriction or the placenta separating early, where it’s called an abruption. 

Dr. Fox: Right. We don’t really know why the location of the placenta is more likely to be a previa as women get older. There’s some theories about it, but no one’s exactly sure why that is, and whether it’s really related specifically to age or some other thing that changes as women get older. And the same with the placenta not functioning so well, a lot of that overlaps with things like IVF, medical issues, potentially her weight gain. And so it’s not entirely clear, but it is true that as women get older, these things become more common. Fortunately, we screen for these routinely. So it’s not something that’s really such a big change in our prenatal care. Like we’re gonna see where the placenta is in all women, regardless of age, but it’s something that they don’t realize. And I think the main two that come up is the risk of gestational diabetes and the risk of preeclampsia. So, in terms of gestational diabetes, is that something you think that women should be concerned about as they get older and are having pregnancies? 

Melka: So the best way I found to explain it to patients is on a scale of 1 to 10. In terms of danger, it’s a one. 

Dr. Fox: Ten is bad, right? 

Melka: Ten is bad. 

Dr. Fox: Okay. 

Melka: In terms of danger, it’s a 1 out of 10. In terms of annoyance, it’s a 12 out of 10 because you have to change your diet, you have to check your sugar’s 4 times a day, the whole pregnancy. You might have to start medication. You can’t eat what you want to eat. You can’t eat when you want to eat. It’s annoying. But it’s typically very, very easy to control. And it’s rare to really see complications related to diabetes. 

Dr. Fox: Yeah, I tell them the same thing. Gestational diabetes is much more of a nuisance than it is a problem. And it is a nuisance. It’s annoying to get that diagnosis. Now, obviously, if you have it and you don’t do anything, you don’t follow it, it could become dangerous. But for people who are, you know, getting good medical care and doing what they’re supposed to be doing, it’s exceedingly unusual that it’s going to be an uncontrollable problem. And, typically, in the women in whom that’s the case, they actually have diabetes, right? It’s not gestational diabetes. It’s, like, real diabetes. And either they knew about it when they came into pregnancy or it just got coincidentally diagnosed when they’re pregnant, because we screened all pregnant women for gestational diabetes. 

But if it’s really just gestational diabetes when you walk into pregnancy without diabetes, it’s, like, I agree 12 out of 10 nuisance, 1 out of 10 danger. So even though it’s more common, I don’t discourage people from pregnancy, or I just warn them, “Hey, you know, you may be dealing with this. Such is life.” Again, age is a factor. Weight is a bigger factor than age. And turns out, as we get older, we tend to get heavier, not everybody, but some of us, myself included, do, and some of it is that, some of it is metabolic related to age, and there’s obviously overlap. I find that preeclampsia is a big one. That is really the one that we’re more concerned about because it’s actually the exact opposite. In terms of nuisance, it’s like 1 out of 10. You don’t have to do anything. You don’t know what’s even happening. 

But, danger, it could range from anything based on how severe the blood pressure is, and most people, when their blood pressure is high, have no symptoms. They don’t know about it. Some will have a headache, but most won’t. And so what do we do? Do we just tell people about this and just freak them out and scare them and say, “Hey, you know, you’re at increased risk for preeclampsia. Good luck. Have a good day.” 

Melka: “Baby aspirin cures everything.” 

Dr. Fox: Yeah, so baby aspirin. 

Melka: Calcium [inaudible 00:14:16]. 

Dr. Fox: Yeah, so we do recommend baby aspirin to women at increased risk for preeclampsia. Women over 35 are included. And everyone does it a little bit differently. Exactly who gets baby aspirin and who doesn’t. The concept is if you’re at increased risk for preeclampsia, baby aspirin should lower that risk a little bit, not a ton, but a little bit, and it’s harmless. Some people argue you should give it to everybody because that’s just easier than trying to sort out who needs it and who doesn’t, because you may miss people. Other people argue, “No, let’s give it for this and this and this,” and who knows? Like, one of those two strategies. But we do give it to women who are over 35, even though the risk really bumps up a lot when you’re over 40. But, again, since there’s not much downside. 

And there’s some data about calcium, mostly for women who are not getting calcium in their diet. So I just ask women, “How much calcium you get?” And if they’re getting plenty, fine. And if they’re not, I tell them to supplement. Generally 1,000 milligrams a day total. And that’s what’s recommended, actually, even when you’re not pregnant. We just had our podcast on osteoporosis with Mike Silverstein. And that’s something that’s recommended anyways for women in this age group. So no reason not to do that. It’s also one of the reasons we check people in the office more frequently to check their blood pressure. 

Melka: It’s amazing, when people talk about prenatal care. Like they think they’re coming in to check the baby. And, like, obviously, they are, but, like, we want them to come in to check their blood pressure, their weight, the protein in their urine, and obviously check the baby. 

Dr. Fox: Right. It was one of these things that we really had to figure out during the pandemic when there was this push to keep people…particularly in the first, like, two, three months to keep people at home. And women didn’t want to come in. They were concerned. They were afraid to you know, leave home, you know, understandably. And so we’re trying to figure out like, “What do we actually need?” And so we saw a bunch of them were like, “All right, you didn’t need an ultrasound today to check the baby. Like, can you go get a blood pressure cuff?” 

Melka: “Get a blood pressure cuff. Is the baby moving?” 

Dr. Fox: Yeah, they have Amazon delivery. Yeah. And that was for a lot of prenatal care, just, “Is your blood pressure okay? Is the baby moving?” And if your blood pressure is okay, we can live without dipping the urine during that visit. And, yeah, that’s really it. There’s not much more. But the blood pressure is key, because, for most women, if their blood pressure is going up, they’re not going to know about it. For some women at really high risk, we’ll actually just tell them, “Get a cuff. Check it every day at home. It’s slightly annoying, but it’s so good to know that you’re safe. You’re okay. It sort of doesn’t make us worry that you have to come and ask frequently, because that’s the main thing we’re checking.” But that is a big one. And that’s also really, really increased as women get older. 

So, like, for example, gestational diabetes, if you look at 35, 40, 45, 50, it goes up, you know, I don’t know, 5%, 6%, to 7%. It goes up a little bit each increment. But preeclampsia goes from like 5 to 10 to 20 to 30. It just really, really bumps up with age because it’s more of a vascular problem, which is affected by age rather than, sort of, a metabolic problem. Fortunately, being over 35 does not seem to increase the risk of delivering early, a preterm birth. So that’s good. That’s a plus. And for most women without any other risk factors, it does not really…it’s debatable whether it impacts the baby’s growth in either direction or another. So we’re not as anal about following the growth if the only risk factor is being over 35. In our practice, it usually is a lot of other things going on, but if that’s all that’s going on, not so much. And I think one of the really difficult ones to talk about is the risk of stillbirth. Because it’s true, there is an increased risk of stillbirth as women get older, but it’s a big downer to talk about that to, sort of, drop that on somebody the first prenatal visit. So what do you do strategically to talk about that? 

Melka: I wrap it into the conversation about the placenta. The placenta always loses function the further you go in the pregnancy. And when you’re over 35, that process happens a little bit earlier. So we start weekly ultrasounds, and we start them at 36 weeks. We do the biophysical profile. Some people do the NST, the non-stress test, something to assess the baby’s wellbeing. 

Dr. Fox: Some people do nothing. You know, it’s one of these things where if you go around the country, around the world, people view this differently about what is the value of these tests? Is it helpful? Is it harmful, potentially, because you’re finding things and intervening and maybe delivering people early? Is it neutral? Do we know? Do we not know? And it’s really true for all the conditions. When we test women, you know, we do it for diabetes, we do it for hypertension, we do it for twins. There’s all these conditions where there’s an increased risk of stillbirth compared to baseline. And we test the baby, you know, more frequently beforehand. And like all those with advanced maternal age, it’s unclear, are these tests very helpful? Are they not? Which test is best? How frequently should you do it? When should you start? And so there isn’t a right or a wrong answer. And so that’s one of the ways we try to lower the risk of stillbirth. And the other way is we, sort of, pick a time to be delivered, meaning don’t go too far past a certain gestational age. And when do you recommend delivery for women who are over 35? 

Melka: Generally by 41 weeks. 

Dr. Fox: Right. A week after the due date. 

Melka: A weak after. Yeah. 

Dr. Fox: Yeah. Did you pick it randomly? I’m just curious. How did you come up with that? 

Melka: I totally made it up. 

Dr. Fox: Yeah. Okay. 

Melka: When I joined the group, you told me that’s what we do. 

Dr. Fox: And so what we did…and there’s been a lot of movement on this, you know, when I started in the practice. And since then, our basic recommendation was we didn’t think it was a good idea for women who are over 35 to go past a week past their due date, because as you said, the placenta function definitely starts to decrease, and if the baseline risk of stillbirth is higher, we don’t want to put, like, risk upon risk. Subsequent to that, there was that study that came out that said if you induce women at 39 weeks, low risk women…there’s also a study with higher risk women who are over 35. You don’t increase the risk of caesarean. So people have gotten much more, I don’t wanna say lenient, but much more open to delivering women earlier, like at 40 weeks or 39 weeks. 

And there isn’t a right or a wrong here, because, you know, I was just having this conversation with someone today. She’s 40 years old. She’s healthy. This is her first pregnancy. Everything is going fine. Perfectly fine. She’s 37 weeks. And I was talking about this about we have to find a time to deliver. And I said, “My personal opinion is everything is going well. I will not deliver you before 39 weeks because there’s potentially some issues with the baby, not so much prematurity but higher chance of going to the NICU, whatever, and I wouldn’t have you go past 41 weeks [inaudible 00:20:42] this. There’s a two-week window.” 

And I said, “I’m very comfortable with anything in that window as long as, you know, we’re monitoring you and everything looks okay. The reasons you may want to go on the early side of that window is, number one, you’re just like, ‘I’m done. I don’t want to be pregnant anymore,’” which is totally reasonable, right? It’s uncomfortable for a lot of women to be pregnant, physically. And number two, if you have a specific fear of stillbirth or something like that, delivery at 39 weeks, you won’t be home for the next, you know, week or 2. On the other hand, if you have a strong desire not to be induced and to go into labor on your own, sort of let it happen “naturally,” then you’re going to wait a little bit longer. And there isn’t a perfect answer to this. And it’s a discussion, and different women feel differently. But we absolutely do monitor in between that time. Have you found that, you know, the women you talked to about this are trying to stay pregnant as long as possible to 41, like, to push it there? Or would rather just deliver earlier? And if so, why? 

Melka: It’s pretty mixed. I think it’s less about when they want to deliver and the concern about induction leading to C-section. And even though I can say we have the studies, you know, “You fit into this age group, whatever,” their worry is still, “Well, if I get induced at 39 weeks because I’m uncomfortable and I end up with a C-section, I’m going to feel bad. And even if I had a C-section at 41 weeks, I would still be upset about a C-section, but I wouldn’t feel like it was my fault.” Some people literally come in and they say, “I don’t care how I deliver. I just want to deliver as soon as possible. Like, schedule my induction at 39 weeks. If it doesn’t work, it doesn’t work, and I end up with a C-section. Oh, well.” 

Dr. Fox: Right. Either because they’re just they’re done, they’re smoked. Or sometimes if they had a bad outcome, the last pregnancy, the baby was sick or whatever, even, you know, God forbid, they had a stillbirth or something before, they’re clearly going to want to be delivered as early as we’ll sort of, “allow” them. It’s true. I really don’t have a strong opinion about that. And it may be to 39 to 41 weeks. And one of the reasons is we actually did a…we did a very big study in our own practice to look at this, because we’ve been doing this testing on women over 35, you know, for 15 years before it was cool to do it. And when we were doing it, we, sort of, you know, had all these women, they were over 35, and we decided we’re gonna do this weekly testing of 36 weeks and deliver them some time by 41 weeks. That was sort of our protocol. 

And what we did is we…this was, you know, thousands of women we’re talking about, and we looked at their likelihood of stillbirth, right? Because stillbirth does happen. It happens in our practice. It happens in every practice, fortunately, very, very low, well less than 1%. But when we looked at it, the rate of stillbirth in the group of women over 35 and over 40 was no different. It was not higher than the general population of women under 35. And what that tells us is that there are some causes of stillbirth that are just not preventable, right? Their cord, you know, gets wrapped around, you know, something and, again, if you prevent it, it’s just by luck that you delivered before that happened. But there’s no way you can predict or prevent it. 

But doing this strategy seems to mitigate whatever risk came from being over 35 or over 40, whatever that was seems to be relieved by this testing. So we were comfortable telling women, “If we do this, you come every week, we deliver you by 41 weeks, whatever your rate of stillbirth is,” which is a horrible thing to think about, “is not higher because of your age.” So that’s why we still sort of are okay going to 41 weeks, where some practices deliver everyone at 39 weeks if they’re over 35, which maybe that’s fine, too. It’s not a wrong strategy, but we’re comfortable with our strategy. Another thing I think that a lot of people don’t realize is the risk of caesarian is increased with age. And do you find that your patients are surprised to learn this? 

Melka: Yes. Very much so. 

Dr. Fox: Yeah. And how do you explain why that is? 

Melka: I don’t have a good explanation. Yeah, some of it is comorbidities. You know, we talked about other risk factors. And those are things that might increase the risk of C-section, 

Dr. Fox: Right. Yeah, absolutely. Like if the baby’s growth restricted or if she has preeclampsia, like, these things do increase the risk. I actually tell women that it seems to be that there’s two theories other than that, and I think they’re both true. The first is, women, as they get older, tend to be a little bit more conservative with these health decisions. And, you know, someone who’s 45 is much more likely to say…again, not everybody, but is much more likely to say, “Forget it. I’m just having a C-section. Like, all as well, don’t worry about it, it’s okay. You know, it’s my first pregnancy. I didn’t do IVF six times. Like, it’s fine. I got other things to think about.” Or, you know, maybe she’s had other deliveries or whatever. And, also, on the doctor, sometimes doctors are a little less likely to sort of push it, so to speak, on a woman who is older. 

And so there’s that sort of psychological component, which I believe is real. I think that’s true both in patients and doctors. But I think even on top of that, for someone who’s highly motivated as a patient to deliver vaginally and a doctor is highly motivated to do it, there’s something physiologically. Our muscles don’t function as well in our 40s as they do in our 30s, as they do in our 20s. Those of us who, you know, live through life, realize that very quickly, and the uterus is a muscle, and it needs to contract. And there’s probably something related to that, that the labors just don’t function as well as you get older. And so I always warn women, not to be a downer, but just that expectations are set, and we’re happy, you know, to try and to be very, you know, patient and quote “aggressive” about a vaginal delivery. But if someone’s, you know, in their 40s, the risk of a C-section is much higher than if she’s in her 20s, all things being equal. And that’s just the reality of it, unfortunately. 

Melka: I think that’s one thing women struggle with a lot. You know, they’re often coming into pregnancy, sometimes with prior miscarriages, with infertility, with IVF. You know, there are women that come in with IVF. And they say, like, “The delivery is the only thing that’s going to be normal.” 

Dr. Fox: Right. 

Melka: You know, like, “Nothing about this pregnancy has been normal. I want something that’s normal, like everyone else.” And it’s hard for them where that’s not always the case, 

Dr. Fox: It’s a conversation that I always have. I have with everybody, you know, there’s always a risk of having a caesarian when you didn’t want one or didn’t expect one. And that’s true for anybody who’s pregnant. It’s just the odds of it are higher if you’re in your 40s and if you’re in your 20s. If you’re in your 20s, the odds are, you know, 15% on the first baby, 20%, somewhere in that range. And if you’re in your 40s, it’s 40% to 50%. It’s just sort of how it is. Again, same practicing doctors, same sort of management of labor, same hospitals, same everything. It’s just that’s just how it is. 

And then, obviously, I think it’s true that as women get older, they tend to have more symptoms related to pregnancy. It’s not universally that way. There’s some women in their 30s and 40s who are, like, feel great, and others who are, you know, 22, or just a wreck. Anyone could have any range of symptoms. But I think, on average, it tends to be a little bit harder, particularly if it’s not someone’s first pregnancy. And not only are they pregnant at 40, but they’re running after… 

Melka: A toddler, yes. 

Dr. Fox: …a 5-year-old and a 2-year old and they’re like, “My God.” 

Melka: And often working. You know, I see that too. Women that are, you know, in their 30s and 40s that had…are very successful, you know, have high pressure jobs, you know, work a lot, and, physically, it wears on you. 

Dr. Fox: Right. When we see someone who is over 35 and beginning a pregnancy, other than the counseling we’re talking about and giving them baby aspirin, as we said, and then at the end of pregnancy, doing this testing, do you manage their pregnancies any differently, otherwise? 

Melka: No. There’s not much else. 

Dr. Fox: Yeah, it’s really those things at the front end and the back end. In the middle of pregnancy…and she may have more symptoms, she may not. We’ll address them as they come. But, basically, for most women, if it’s, you know, a function of their age, and they don’t have the other…they don’t have high blood pressure, they don’t have diabetes, and we don’t, you know, sort of manage those, her pregnancy management’s very similar to everybody else. The frequency of prenatal visits is the same. The tests we do are the same. The ultrasounds we do are the same. The counseling we do is the same. Diet and exercise is the same. All of these are really the same. The takeaway message for women is, as women get older, there are some things that increase in risk that there’s nothing that anyone can do about, so to speak, particularly, you know, related to fertility and miscarriage. Fortunately, if that does happen, there are treatments available so that women can get pregnant, basically, any age, assuming they have, you know, good fertility doctors and who know what they’re doing. But that’s something that’s just sort of a function of age. 

And then after that, there’s just a few modifications we do in pregnancy, in terms of the baby aspirin and some of the things at the end and making a decision about when to deliver. And then there’s a slightly increased risk of caesarian. But, otherwise, it should go well, particularly if someone is healthy. So if I have someone, you know, a friend of mine or patient of mine or a relative 35, 38, 40, 42 and is talking to me about getting pregnant, “Well, I think if you’re healthy, and you feel well, you should do great in a pregnancy. It should go fine. And it’s not something to be worried about or be afraid for any more so than anyone else is pregnant. But just make sure that you’re seeing someone who knows what they’re doing. And that’s it.” It doesn’t necessarily have to be a high risk doctor, so to speak, could be but many, many, you know, non-high risk doctors and practices take care of women who are over 35 all the time, and as long as they know what they’re doing, it should go very well. 

Melka: Yeah. One thing we didn’t really get into is women that have had babies before. And, you know, when I was a resident, you learn, like, if you had “blank” in a prior pregnancy, that’s a risk factor for having “blank” again. And you sort of laugh at it. And then you see it in real life, and you’re like, “Wow, that’s really true.” So for someone who comes to me that says, “I’m 39. I’ve had two kids. Am I too old to have a third?” And their two pregnancies were totally uncomplicated. Like their likelihood is very good to have another uncomplicated pregnancy. 

Dr. Fox: Right. And particularly also the caesarean rate isn’t so high. So if they had two vaginal deliveries before, almost whatever her age is, she has a very, very, very high chance of delivering vaginally again. 

Melka: Yeah. And then we have people that have had, you know, three pregnancies. They’ve been gestational diabetic in all three. And by the fourth one, they’re like, “Can I not even do the sugar test? Like, we know I’m going to be diabetic. We know it’s gonna happen again.” 

Dr. Fox: Right. Right. Or hypertension. These things definitely tend to repeat themselves. Not always, but a much higher risk. And that’s also part of the counseling, you know, someone who’s 40 and saying, “Should I get pregnant?” If her past three pregnancies were disasters, Yeah, well, it’s going to probably be the same and maybe worse, and doesn’t mean you shouldn’t do it. It just means we have to talk about it. Whereas if they went really smoothly, again, maybe there’ll be an issue of fertility, maybe a higher chance of miscarriage. But other than that, it really should go very well if they went well before. Melka, tell me, what did you feel like on the day of your 35th birthday, being an obstetrician, when you became advanced maternal age? 

Melka: I believe I was seven weeks pregnant. So I spent the whole day throwing up, not because I was partying but because pregnancy is miserable. It was uneventful. 

Dr. Fox: Yeah, I remember when I turned 35, I was like, “I’m advanced maternal age today.” I was like, “Yeah, I don’t feel much different from yesterday.” 

Melka: Not at all. 

Dr. Fox: And I always would tell, you know, women now [inaudible 00:31:55], like, nothing magically happens when you turn 35. Like, you know, sometimes people will get counseled, like, you know, “If you’re 35 and over, you need to do A, B, C, D, and E. And if you’re 34 years, 11 months, you know, and 30 days and younger, you’re perfectly fine.” And, obviously, that’s not the case. These things are all, like, a gradation. As you get older, these risks go up slightly, but nothing actually happens at 35. Again, that cut off was just…you know, it happened to be the risk [inaudible 00:32:24] Down syndrome. And that’s why 35 was picked. It could have been a different age. 

Melka: I’ve had women under 35 be told by someone, like, who knows, that they… 

Dr. Fox: Impending [crosstalk 00:32:33]. 

Melka: No, no, no, that they can’t have an amnio because they’re not 35. And I had like a handful of people that are like late 20s, early 30s. That’s something like a close friend, or a sibling or someone with an abnormal pregnancy and they’re like, “I just want to do a CVS and know that everything is normal.” We’re like, “‘Yes, you can do that.” 

Dr. Fox: Yeah, absolutely. It’s allowed. For any of our listeners out there who are over 35 or coming up on 35 and wondering about pregnancy, hopefully, this podcast was mostly reassuring. If you’re in good health and you’re fit and all as well, you should do great. If you have any specific concerns or you want to talk more, definitely see your own OB-GYN, or if we’re your OB-GYNs, come see us. We’re happy to talk about it to you before pregnancy or an early pregnancy. But, again, the message is, most do very, very well. Age alone is not a reason not to get pregnant. It’s something we need to consider and talk about. But we pretty much, I mean, never tell women, “You can’t get pregnant because of the age alone.” 

And I mean, I see women for consultations who are, you know, 40, 45, 50, 55, and I see women, you know, in those age groups, and there’s a lot to talk about and to think about, but it’s not the number. It’s not age that’s going to affect it. It’s a lot of the other things in terms of our health. Melka? 

Melka; Thanks for doing this. 

Dr. Fox: This is great. Hey, any of you guys have requests out there, you can send us an email. We’re happy to cover the topics. I’ve been getting some, and it’s great. We’re trying to cover all them. Same if you want to talk about your own pregnancy and your own birth, tell your high risk birth story. It doesn’t have to be high risk. It could be low risk and a good outcome. If you got a good story to tell, we’re happy to hear it. Melka told hers, which was great. Feel free to email it in. I absolutely positively read all the comments that come on to Apple and all the emails that come into our inbox. So feel free to shoot us an email with a suggestion or if you want to tell your own story. Thanks, Melka. 

Melka: Thank you. 

Dr. Fox: Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@ healthfulwoman.com. Have a great day. 

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.