HEALTH & FITNESS

Pregnancy in older women
With increasing life expectancy, improved health and career options, delay in starting a family is common. Women should be aware of the decreased fertility potential and other implications as their age increases
Dr Umesh N. Jindal

Pregnancy in older women is rarely considered a medical problem as excellent management options are now available. However, there is a need to increase awareness about this fact considering its implications on both the maternal and the child health.

Pre-conception counselling becomes the norm
New Delhi: When 32-year-old Amita (name changed) and her husband went to see a gynaecologist after she suffered a miscarriage, they were shocked to know that the anti-pimple cream she uses regularly could be the reason for causing difficulties in her pregnancy. Lack of awareness, stress and late pregnancy are all factors that can cause difficulties while trying to conceive, making pre-conception counselling crucial, doctors say.

 

 

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Pregnancy in older women
With increasing life expectancy, improved health and career options, delay in starting a family is common. Women should be aware of the decreased fertility potential and other implications as their age increases
Dr Umesh N. Jindal

Pregnancy in older women is rarely considered a medical problem as excellent management options are now available. However, there is a need to increase awareness about this fact considering its implications on both the maternal and the child health.

Young women may delay motherhood for various reasons like career, marital and financial stability, migration and many other socio-cultural reasons. Unfortunately, this decision is usually based on misconceptions rather than facts. The irony is young women underestimate their fertility and land up with unwanted pregnancies in youth, while older women overestimate their fertility potential.

The average age of first-time mothers has increased from 21.4 years in 1970 to 25.1 years in 2008 globally. While in 1970, 1 in 100 women had their first baby after 35 years, the rate has increased to one in 12 in 2006. There is a 30-40-fold increase in IVF procedures in women above 40 years all over the world.

Smita, (30), an MBA, was planning to pursue further studies and a job in USA. She wanted her eggs to be preserved to overcome any fertility issues later in life.

Seema, (34.5 years), only three months into marriage, wanted an IVF treatment so as to conceive before her 35th birthday in order to avoid complications which are often associated with mid-thirties pregnancies.

Renu, 42, had been married for 10 years but could not conceive even after undergoing fertility treatment for many years. She got a shock when she was told that her ovaries were exhausted and she would need egg donation. She believed that normal menstruation is equivalent to fertility. (All names have been changed).

"Older" women in the context of their reproductive potential are women above 35 years. They still have their natural fertility potential albeit at a lower level. Women above 45 years, in whom only anecdotal natural conceptions occur, can be called "elderly" as far as their reproductive life is concerned.

Age-related risks
Most health risks are related to the age of a woman.

* Probability of conception: Reproductive lifespan of a woman ends almost 10 to 12 years before the age of menopause. Ovaries, which have a fixed quota of eggs at birth, are depleted completely at menopause. The best-quality eggs are lost much before the menopause. Fertility starts declining slowly at 28, quite rapidly after 35 and becomes negligible after 40. Only one in 10 women will be able to conceive after 40.

* Risk of abortion: Almost 15 per cent of all pregnancies are aborted in older women. More than 60 per cent of such abortions happen because of implantation of genetically-abnormal embryos. The risk of a non-viable, genetically abnormal pregnancy increases with age. The risk of abortion increases from 10 per cent in the twenties to more than 30 per cent in the late thirties to greater than 50 per cent above 40 years.

* Risk of abnormal babies: The risk of malformed babies is approximately 1 per cent in general population which increases to 3-4 per cent in older women. But the risk of mental retardation or Down's syndrome increases manifold. The risk of Down's syndrome for a woman at 25 is 1 in 800 deliveries, which rises to 1 in 250 at 37 and 1 in 40 above 40.

These risks can be overcome by proper monitoring in early pregnancy with the help of sonography tests and biochemical tests.

* Risk of maternal complications: A pregnant woman may develop many medical problems in first-time pregnancy like high blood pressure, diabetes, bleeding during late pregnancy etc. The risk of all these problems increases with age. Obesity, sedentary lifestyle, smoking, alcohol and other medical diseases aggravate such problems. Women in the late thirties are more likely to have operative deliveries.

Pre-pregnancy evaluation: A general health checkup to rule out common medical problems like anaemia, sexually transmitted diseases, diabetes, thyroid disorders and high blood pressure is necessary. A trans-vaginal ultrasound may be done to know if internal organs are normal. Most of the times, occurrence of pregnancy itself is the biggest evidence of normal functioning of reproductive tract even if some problems like fibroids or abnormal shape of uterus is detected on ultrasound. As a pre-conceptional measure, intake of folic acid and vitamin B 12 for three months is strongly recommended at all ages to reduce the chances of abnormal babies. Shedding extra kilos, refraining from smoking and alcohol and maintaining an active lifestyle is very important before embarking upon a pregnancy.

Tests during pregnancy

* Ultrasound for foetal well being: Major abnormalities can be detected and growth assessed. Ultrasound and Doppler can also assess the blood supply and oxygenation to the baby. These tests also help in the timing of delivery in complicated pregnancies.

Two important scans to exclude foetal abnormalities are at 11-13 week (this can detect major abnormalities and signs of Down's syndrome) and at 16-18 week.

However, there is no remedy for major abnormalities. Only treatment is abortion which can be done only up to 20 weeks.

* The second group of tests is screening for genetic abnormalities. These are the Dual test or double-marker tests done in third month, triple or quadruple test done at 16-18 weeks of pregnancy. These tests are based on certain chemicals secreted by baby and placenta into the maternal circulation. These are only screening tests and give only a risk assessment. If a higher risk for an abnormal baby is found then amniocentesis is performed for confirmation.

A combination of ultrasound and blood tests is likely to detect majority of the abnormal babies.

* Monitoring for maternal health: Regular check ups for BP and haemoglobin is required in all pregnancies. A glucose tolerance test (GTT) is done to detect diabetes. Women in their thirties require more frequent visits to the doctor.

There is no evidence that 30-plus women require any special supplements or nutrients as compared to younger women. Important pre-natal vitamins include folic and, iron, calcium and trace elements like zinc etc. Most of these are available in a healthy and balanced diet that includes fruits and vegetables.

The contribution of the age of male partner is often overlooked. Increasing age of the male partner is a significant factor for decreased fertility of the couple. Contribution towards increased risk of abortions and abnormalities is not well known but cannot be ruled out.

To conclude, conception in later ages is difficult and has higher risks for the mother and the baby but can be managed with expert and regular antenatal care. However, this should not push women to go for unwarranted infertility treatment to speed up the process. General health of women determines the likelihood of pregnancy and risk of complications.


The cost of motherhood

Besides medical problems, it may be quite costly to have a baby at a later age. The increased number of visits, investigations, ultrasounds, hospital admissions and operative deliveries all add to higher cost. While the medical cost of managing an uncomplicated pregnancy at 25 years ranges from Rs 20,000- Rs 50,000 in private health care, it may go up to 5-10 fold in the late thirties. In addition, if there is a problem with conception then cost of infertility care can range from Rs 20,000 to few lakhs. An average IVF cycle costs Rs 1.5 lakh to Rs 2 lakh in India.

The writer is a Chandigarh-based senior gynaecologist

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Pre-conception counselling becomes the norm 

New Delhi: When 32-year-old Amita (name changed) and her husband went to see a gynaecologist after she suffered a miscarriage, they were shocked to know that the anti-pimple cream she uses regularly could be the reason for causing difficulties in her pregnancy. Lack of awareness, stress and late pregnancy are all factors that can cause difficulties while trying to conceive, making pre-conception counselling crucial, doctors say.

"The cream Amita was using had Isotretinoin, which is an X-category element that can cause anomalies in the child. Such creams must be stopped at least three months before one is trying to conceive. But because of lack of awareness, she had a miscarriage," says Shivani Sachdev Gour, a Delhi-based gynaecologist.

Pre-conception counselling is slowly becoming the norm in urban India. Doctors, however, say that most couples still come after they have hit a roadblock, adding that nearly 15-20 per cent of their patients have pregnancy-related complications that are mostly lifestyle-related.

"Most couples come to us after six months to one year of trying to get pregnant and not succeeding," says Dr Richa Jagtap, a Mumbai-based fertility expert. "In today's times, when everything is getting delayed late marriage, late pregnancy and there is so much stress to add to it, getting pregnant can be difficult or complicated. But not in all cases do you need treatment. With just the right guidance you can avoid complications if you seek advice earlier," Dr Jagtap adds.

One of the first things a couple is advised when they come for such counselling is a health check-up. "Pre-conception counselling should ideally be done three-six months before planning pregnancy. When a couple comes to us, we put the woman on a folic acid supplement and determine any risk factor that she may have, like diabetes or heart disease, and guide accordingly," Dr Chetna Joshi, a gynaecologist at Gurgaon's.

Medical tests such as for thyroid disorder, thalassemia, blood sugar, haemoglobin, and rubella are prescribed and a hormonal profile is drawn up. If the couple agrees, tests for HIV status and hepatitis B and C are also advised.

"A test for thalessemia, for instance, is important because if the woman is thalessemia minor and so is the man, this can be catastrophic for the baby. There is one in four chances of inheriting the disorder and there could be multiple abortions," says Dr Madhu Ahuja, a gynaecologist at New Delhi's Max Hospital.

If conceiving is difficult and the woman is obese, she is also tested for polycystic ovary. Doctors say that polycystic ovary and endometriosis tests are becoming common these days. In some cases husbands may also be asked to take a semen analysis.

"We also see if any drug that the patient may be using needs to be changed," Dr Joshi said. "Acne treatment, for instance, must be stopped three months before planning pregnancy even if it's a local application and so should vitamin A applications".

But all said and done, doctors say that if a woman is below 30 years of age, the couple can take two years before seeking help, if the woman is 30 they should take a year, and if she is above 30, they should seek help after trying for six months because there is a "sharp decline in fertility between 35 to 37 years of age".

"We also advise couples on the best time for conception. Good guidance is sometimes all that is needed. And if treatment is required, early detection helps you do something instead of spending days in confusion and helplessness," Dr Ahuja noted. IANS

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