Pregnancy at Midlife | Expert Insights by Dr. Laxmi Shrikhande

 Chairperson Indian College of OB/GY 2022--2023
 National Corresponding Editor-Journal of OB/GY of
India JOGI since last 8 years
 National Corresponding Secretary- Association of
Medical Women, India
 Member-SAFOG Education Committee
 Vice President Elect ISOPARB 2016-17
 Joint Secretary-Indian Menopause Society 2024
 President –ISOPARB Vidarbha Chapter 2019-21
 Chairperson-IMS Education Committee 2021-23
 Chairperson-fertility enhancement Committee-
ISOPARB 2023-24
 President-Association of Medical Women, Nagpur
AMWN 2021-24
 President Menopause Society, Nagpur 2016-18
 Senior Vice President FOGSI 2012
 President Nagpur OB/GY Society 2005-06
Dr. Laxmi Shrikhande
MBBS; MD(OB/GY); FICOG;
FICMU; FICMCH; FIMS
Medical Director &
Senior Consultant -
Shrikhande Hospital &
Research Centre Pvt Ltd,
Nagpur, Maharashtra
 FRCOG –Fellow Hon. Causa by
Royal College of OB/GY, UK
 Nagpur Ratan Award at the
hands of Union Minister Shri
Nitinji Gadkari
 Received Bharat excellence
Award for women’s health
 Best Committee Award as
Chairperson HIV/AIDS
Committee, FOGSI 2007-2009
 Received appreciation letter
from Maharashtra Government
for her work in the field of
SAVE THE GIRL CHILD
• Delivered 32 orations and
550 guest lectures
• Publications- 62 National &
31 International
• Sensitized 2 lakh boys and
girls on adolescent health
issues
Awards
Positions

Pregnancy at Midlife
Dr Laxmi Shrikhande
Consultant –Shrikhande Hospital & Research Centre Pvt Ltd
Nagpur

Pregnancy @ Midlife
 Number of women giving birth at midlife is
increasing all over the world.
 This is due to the later marriage, second
marriage, the availability of better
contraceptive options, and wider
opportunities for further education and
career advancement.

Spontaneous abortion —
 Older women experience an increased rate of spontaneous abortion .
 These losses are both trisomic and euploid and primarily result from
 a decline in oocyte quality;
 changes in uterine and hormonal function may also play a role.
 The vast majority of losses occur between 6 and 14 weeks of
gestation.

Ectopic pregnancy —
 Maternal age ≥35 years is associated with a four- to eightfold
increased risk of ectopic pregnancy compared with younger women .
 The ectopic pregnancy mortality is greatly influenced by both
advanced maternal age and race .

Chromosomal abnormalities —
 There is steady increase in the risk of aneuploidy as a woman ages .
 The most common aneuploidy is autosomal trisomy.
 Preimplantation selection of chromosomally and morphologically
normal embryos could increase the chances of successful
implantation and ongoing pregnancy, as well as avoid chromosomally
abnormal births in the settings of Assisted Reproduction.

Gene abnormalities —
 There are sparse data on the effect of advanced maternal age on
single gene disorders and epigenetic events, other than in the setting
of assisted reproduction.
 Epidemiologic studies have reported an association between
advanced maternal and paternal age and risk of autism spectrum
disorders in offspring .

Congenital malformations —
 The risk of having a child with a congenital anomaly may increase with
increasing maternal age .
 Historically, an increase in congenital anomalies with advancing
maternal age has been attributed to the recognized increase of
aneuploidy with advancing maternal age and the association of
aneuploid fetuses with structural anomalies.
 However, several analyses have suggested that the risk of non-
chromosomal anomalies also increases as women age.
 Cardiac anomalies, in particular, seem to increase with maternal age
independent of aneuploidy.

New shift
 Some very important complications that occur later in pregnancy can be predicted in
the first trimester itself.
 Inverted pyramid helps in dividing cases into high risk & low risk in the first trimester
Nicolaides KH. Turning the pyramid of prenatal care. Fetal Diagn Ther 2011;29: 183–96.

USG @ 6-7 weeks
 Exact dating of pregnancy
 Ectopic pregnancy/ Heterotopic pregnancy
 Missed abortion
 Single /Multiple pregnancy
 If Multiple-Chorionicity

Screening for Trisomy 21 at 11- 14 weeks for
India
2-stage (contingency) screening proposed
RISK ESTIMATE BY ONLY USG N.T. AND OTHER MARKERS
Fetal NT
Nasal bone and
ductus venosus
tricuspid
regurgitation at 12
wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Free B hCG
PAPP-A
THIS WILL SAVE
TIME
MONEY
OPTIMUM USE OF OUR
SKILL
DOUBLE MARKER
TEST
Scan 20w NIPT

Prenatal diagnosis
 Nuchal translucency measurement with maternal age is the best
method for aneuploidy screening
 Advantage: fetus specific
 Structural anomaly scan for NTDs
 Combine NT scan with Uterine artery Doppler,
 Tricuspid flow and DV -95-97%

Antenatal care
 Screening for the pregnant woman:
 Gestational diabetes
 Pre-eclampsia and preterm labour
 Placenta Previa
 Asymptomatic bacteriuria
 Chlamydia.

Cervical length screening routine to prevent
preterm labour
Asymptomatic singleton pregnancy a TVS cervical length <25 mm
in second trimester
Screen at 11-13 weeks and then at 22-24 weeks

Obstetric complications
 Some obstetric complications in older women appear to be related to
the
 aging process alone, while others are
 largely related to coexisting factors such as multiple gestation,
 higher parity, and
 chronic medical conditions, which are less likely to be observed in younger
women.
 All these factors may contribute to increased pregnancy-related
maternal morbidity that is reported in older women.

 In a population-based study of nearly 830,000 singleton births from Washington
State, women ages ≥40 years had
 an eightfold increased risk of amniotic fluid embolism and
 threefold increased risk of obstetric shock compared with women age 25 to 29
years .
 Women in the age 45 to 49 category had a 16-fold increased risk of renal failure
and nearly fivefold increased risk of both obstetric intervention and admission to
the intensive care unit.
Lisonkova S, Potts J, Muraca GM, et al. Maternal age and severe maternal morbidity: A population-based retrospective cohort study. PLoS Med 2017; 14:e1002307

 Similarly, a retrospective cohort analysis of nearly 37 million deliveries
between 2006 and 2015 reported that women between 45 - 54 years had
 nearly 3.5 times the risk of severe maternal morbidity (compared with
women ages 25 to 29) and
 had the highest rates of
 cesarean delivery,
 preeclampsia,
 postpartum hemorrhage,
 gestational diabetes,
 thrombosis, and
 hysterectomy in adjusted analysis .

Effects of coexisting medical conditions —
 The prevalence of medical and surgical illnesses, such as cancer; cardiovascular,
renal, and autoimmune disease; and obesity increases with advancing age.
 For this reason, women ≥35 years of age can expect to experience two- to threefold
higher rates of hospitalization, cesarean delivery, and pregnancy-related
complications than their younger counterparts.
 Smoking has been associated with increased perinatal morbidity and stillbirth in all
age groups, but the risk is particularly high in older smokers .
 The two most common medical problems complicating pregnancy are hypertension
(preexisting and pregnancy related) and diabetes (pregestational and gestational).
 Both conditions are increased in older women, especially those who are overweight.

Hypertension —
 The odds of being diagnosed with chronic hypertension are two- to
fourfold higher in women ≥35 years of age than in women 30 to 34
years of age and for women ≥45 years compared with those 35 to 44
years .
 The incidence of preeclampsia in the general obstetric population is 3
to 4 percent; this increases to 5 to 10 percent in women over age 40
and is as high as 35 percent in women over age 50 .
 Maternal and fetal morbidity and mortality related to hypertensive
disorders during pregnancy can be reduced with careful monitoring
and appropriately timed intervention.

Diabetes mellitus —
 The prevalence of diabetes increases with maternal age; the rates of both
preexisting diabetes mellitus and gestational diabetes increase three- to
sixfold in women 40 years of age or older compared with women aged 20 to
29 .
 The incidence of gestational diabetes in the general obstetric population is 3
percent, rising to 7 to 12 percent in women over age 40, and 20 percent in
women over age 50 .
 Preexisting diabetes is associated with increased risks of congenital
anomalies, perinatal mortality, and perinatal morbidity, while the major
complication of gestational diabetes is macrosomia and its sequelae .

Placental problems —
 The prevalence of placental problems, such as abruptio placenta and placenta
previa, is higher among older women.
 Multiparity accounts for significant proportion of the excess risk in both
disorders.
 In fact, there is no significant correlation between maternal age and
abruption when parity and hypertension are taken into account.
 In contrast, age, as well as parity, appear to be independent risk factors for
placenta previa.
 Nulliparous women ≥40 years of age have a 10-fold increased risk of placenta
previa compared with nulliparous women age 20 to 29 years, although the
absolute risk is small (0.25 versus 0.03 percent) .

ANC care @ 18-20 weeks
Quadruple Marker
Anomaly scan
Cervical length
P/S exam
NIPT/Amniocentesis
Fetal ECHO @ 22 weeks

ANC
 DIPSI
 Regular Surveillance
 Cervical length
 Low dose aspirin

Third trimester
 Close monitoring for foetal growth
 Close monitoring for preterm labour
 Pay special attention to Placenta-praevia, adherent placenta
 Maternal ECHO
Sun LM, Walker MC, Cao HL, et al. Assisted reproductive technology and placenta-mediated adverse pregnancy outco
mes.
Obstet Gynecol 2009; 114:818.
Romundstad LB, Romundstad PR, Sunde A, et al. Increased risk of placenta previa
in pregnancies following IVF/ICSI; a comparison of ART and non-ART pregnancies in the same mother. Hum
Reprod 2006; 21:2353.

Antepartum Fetal Surveillance
 The goal of antepartum fetal surveillance is to reduce the risk of stillbirth.
Various Methods-
 Clinical assessment by uterine growth
 Fetal movement count by the mother
 Ultrasound for fetal growth
 NST and CTG
 Biophysical profile
 Doppler studies
 Placental grading

Perinatal morbidity —
 Advanced maternal age is responsible for a substantial proportion of
the increased rate of low birth weight (LBW) and preterm delivery
(PTD) observed in the past several years .
 Although older mothers have more PTDs, their preterm neonates are
not at increased risk of morbidity compared with preterm neonates of
younger women.

Perinatal mortality-
 Large studies worldwide consistently report that older women (≥35
years of age) are at significantly increased risk of stillbirth compared
with younger women.
 A systematic review and meta-analysis of these studies calculated that
maternal age older than 35 years was associated with a 65 percent
increase in the odds of stillbirth (effect size 1.65, 95% CI 1.61-1.71)
compared with younger women .
 The relative risk of stillbirth increased with increasing maternal age (ie,
higher at age 40 than at age 35).

Perinatal mortality-
 The increased risk of stillbirth is most notable after approximately 37
weeks of gestation .
 The excess perinatal mortality experienced by older women is largely
due to non-anomalous fetal deaths, which are often unexplained,
even after controlling for risk factors such as hypertension, diabetes,
antepartum bleeding, smoking, and multiple gestation .
 Nevertheless, the absolute risk of stillbirth in developed countries is
small, even at very advanced maternal ages.

Neonatal death —
 In contrast to the increased risk of stillbirth with increasing maternal
age, the risk of neonatal death among neonates born preterm is lower
than in preterm infants of younger women.
 This may have been due to differences in underlying factors, such as
 higher use of prenatal steroids and
 cesarean delivery and
 lower rates of substance abuse, in older women.

Multiple gestation —
 Advancing age is associated with an increased prevalence of twin
pregnancy, which is related to both a higher risk of naturally-
conceived twins and a higher use of ART in older women.
 Interestingly, in contrast to singletons, the outcome of multiple
pregnancies in older women is as good or better than the outcome in
younger women .

Labor and cesarean delivery —
 The optimum gestational age for delivery of women of advancing age is
unclear.
 While some data support delivery in the 39th
week of gestation, which
has not been associated with an increase in the risk of cesarean
delivery and appears to be cost neutral .
 Studies consistently report that women ≥35 years of age are more likely
than younger women to experience labor dystocia and be delivered by
cesarean .

Labor and cesarean delivery —
 In a United States cohort study of over 78,000 singleton births between
2003 and 2012, the proportion of women undergoing a primary cesarean
delivery increased with age for both primiparous and multiparous women
(women with a prior cesarean delivery were excluded from study) .
 By years of age, the primary cesarean delivery rate was 20 % for women
ages 25 - 34 years, 26 % for women 35 - 39 years, 31 % for women 40 - 44
years, 36 % for women 45 - 49 years, and 61 % for women ≥50 years.
 For comparison, the overall primary cesarean delivery rate for singleton
births in the United States was approximately 22 % during a similar time
period .

In IVF pregnancies , does delivery at 39 weeks reduce
the risk of adverse perinatal outcomes?
 It is currently unknown whether elective delivery at 39 weeks reduces the risks of maternal
morbidity and improves perinatal outcomes in IVF pregnancies compared with expectant
management.
 A systematic review revealed that in asymptomatic uncomplicated singleton gestations,
induction of labor between 39 0/7 and 40 6/7 weeks does not increase the risk of
cesarean delivery compared with expectant management but does not reduce the rates of
adverse perinatal outcomes, including perinatal death, low Apgar score at 5 minutes, or
need for NICU admission.
 In the absence of studies focused specifically on timing of delivery IVF pregnancies,
we recommend shared decision-making between patients and healthcare providers
when considering induction of labor at 39 weeks of gestation (GRADE 1C).
Saccone G, Della Corte L, Maruotti GM, et al. Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A
systematic review and meta-analysis of randomized trials. Acta Obstet Gynecol Scand 2019;98(8):958-966.
.Lagrew DC, Kane Low L, Brennan R, et al. National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births-
Supporting Intended Vaginal Births. J Obstet Gynecol Neonatal Nurs 2018;47(2):214-226.

LSCS for all ART / midlife pregnancies ??

LSCS on demand ?? Mahurat LSCS ??

Maternal mortality —
 While maternal mortality is relatively rare, women 40 years or older
are at a sixfold increased risk of maternal death when compared with
women less than 20 years of age .

Parenting —
 An observational study of longitudinal cohorts noted that increasing
maternal age was associated with improved health and development
for children up to 5 years of age .
 Outcomes included frequency of unintentional injuries, immunization
rates, language development, and social development.
 Children of older parents have described several benefits, including
 the devotion,
 patience, and
 attention of their parents, as well as their
 emotional and financial stability .

Parenting —
 On the other hand, older parents should also be aware of the various
issues related to their age on offspring, such as
 possibly being mistaken as grandparents,
 the increased possibility of parental death or serious illness while the child is
young or an adolescent,
 the increased possibility that the young adult child will become a caregiver to
aging parents, and
 generational issues.

Medical —
 The experience of pregnancy at an advanced maternal age may
impact subsequent health as the woman continues to age, both
because of
 changes from the pregnancy itself and
 because of increased risk of pregnancy-related complications that negatively
affect health.

Post partum care
 Puerperal psychosis
 Lactation problems
 Monitoring co-morbidities
 Neonatal care

Pregnancy at Midlife | Expert Insights by Dr. Laxmi Shrikhande

Summary and recommendations
• Women should be informed that delaying childbearing until the mid-
30s significantly increases the risk of infertility and of developing a
chronic medical disease which might complicate pregnancy.
• Women contemplating pregnancy should be counseled to optimize
their health (eg, achieve a normal body mass index and avoid
smoking, recreational drugs, and alcohol) and seek preconceptional
counseling.

Pregnancy complications that occur with increased frequency in older gravidae include:
 ectopic pregnancy,
 spontaneous abortion,
 fetal chromosomal abnormalities,
 some congenital anomalies,
 placenta previa,
 gestational diabetes,
 preeclampsia, and
 cesarean delivery.
 Such complications may, in turn, result in preterm birth.
 There is also an increased risk of perinatal mortality.
Summary and recommendations

The best way to protect the mother's health
and that of the baby regardless of how &
when the pregnancy occurred is good
Antenatal , Intranatal & Postnatal care.

My World of sharing
happiness!
Shrikhande Fertility Clinic
Ph- 91 8805577600
shrikhandedrlaxmi@gmail.com

The Art of Living
Anything that helps
you to become
unconditionally happy
and loving is what is
called spirituality.
H. H. Sri Sri Ravishakar

Pregnancy at Midlife | Expert Insights by Dr. Laxmi Shrikhande

More Related Content

Similar to Pregnancy at Midlife | Expert Insights by Dr. Laxmi Shrikhande (20)

More from Dr.Laxmi Agrawal Shrikhande (20)

Recently uploaded (20)

Pregnancy at Midlife | Expert Insights by Dr. Laxmi Shrikhande