Pregnancy in women aged 40 and older

Counseling patients about pregnancy at advanced maternal age is a difficult process. This is true both because our knowledge of the attendant risks is incomplete and still evolving, and because of the difficulties of assigning risks and addressing counterbalancing benefits for individual patients. There are a number of social and personal considerations involved in a decision to become a parent after the age of 40. Generally, older parents tend to be more mature, to be in stable and healthy marriages, and to have more financial and family resources to assist with the process of child rearing. Parents in their fifth decade, however, may complain of having less energy to devote to young children or may be at a stage in their careers in which they have less time for family participation than when they were younger. Also, grandparents, who can play a critical role in early childhood development, often have become too old to participate in that role or have died. All of these issues must be considered by parents contemplating late childbearing. A great deal has been written, much of it positive, even enthusiastic, about the quality of pregnancy and childbirth among older women. Nevertheless, much of the literature is difficult to interpret because of problems in controlling for confounding variables. In addition, much of the focus on so-called older women has been on those older than 35 years. In fact, the great majority of the medical literature concerning late childbearing relates to women between the ages of 35 and 40. The data that directly concern women in their fifth decade suggest that risks that began to accelerate after the age of 35 become considerably greater and increase more rapidly after the age of 40. Obviously, couples must decide what risks they are willing to accept and how these potential risks might be countervailed by the presumed advantages of parenthood relatively late in the reproductive years. There is convincing evidence to show that fecundity is decreased with advancing maternal age, and various forms of early pregnancy loss are increased. Thus, to delay childbearing results in a significant decrease in the likelihood of becoming pregnant or carrying a pregnancy to term. The possibility of genetic disorders is, as has been discussed previously, relatively easy to quantitate, and most age-related anomalies are amenable to prenatal diagnosis. It seems clear that women with underlying medical diseases, particularly hypertension and diabetes mellitus, contribute heavily to the excess morbidity and mortality associated with late childbearing.(ABSTRACT TRUNCATED AT 400 WORDS)