Pregnant After 40: Risks

More Pregnancies after 40 Means More Pregnancy Risks to Manage

Recently, the news media has been filled with reports about record-low birth rates in the United States, especially over the last decade. One of the more remarkable developments receiving much less attention, however, was the fact that birth rates have been plummeting only in younger women; in older women, and especially in women above age 40, birth rates have actually been increasing to quite surprising degrees.

Especially in more prosperous countries, national birth rates have been plummeting for quite some time, often falling significantly below population replacement rates. Among the most affected regions are economically developed countries such as Japan, South Korea, and Italy. The U.S. population has continued to grow only because of immigration. In the absence of new immigrants, the U.S. population would have stagnated for quite some time. Except for Africa, even in the developing world, birth rates have been declining. China, indeed, reversed her one-child policy because of a rapidly aging population, fearsome that in the not-too-distant future, a decline in working-age adults could cause severe economic difficulties for the country.

In the U.S., women over 40 getting pregnant has proportionally been the most rapidly growing age group having children. This trend has been even more marked at CHR, where the median age of IVF patients was 43 in 2017. Not surprisingly, trends like this are widely considered to predict an economic boom for the fertility industry because they promise continuous growth in treatment cycles over many years to come.

Understanding the Risks for Women Pregnant in their 40s and 50s

CHR is raising this subject because aging patient populations in IVF centers require significantly more attention than younger patients. When a woman becomes pregnant after 40 or even in their 50s, risks naturally increase, requiring more individualized medical care. In our opinion, nothing is as important in providing fertility services to older women than individualization of care, not only when it comes to fertility treatments but also in preparing patients for a potential pregnancy at 40 years old or later, educating them about its risks and mitigating them with proactive, collaborative care.

The principal reasons for higher risks of having a baby after 40 are obvious: Pregnancy creates functional stress on every organ of a woman’s body. CHR’s Medical Director and Chief Scientist, Norbert Gleicher, MD, who for many years, and over a number of different editions, was the editor of the principal textbook on medical problems in pregnancy (Principle & Practice of Medical Therapy in Pregnancy), therefore, coined the phrase, “pregnancy is a universal stress test on the female body." Practically, this means that any bodily function (the skeleton included) is at risk of decompensating during pregnancy if, prior to pregnancy, it already is only marginal in function.

If a woman is interested in getting pregnant at 40, risks naturally increase as the body is less able to manage stress than it was at a younger age. Also, the success rates for achieving a pregnancy and live birth after 40 are substantially lower than in younger patient populations. While this fact shouldn’t dissuade any woman from pursuing pregnancy, fertility treatments, or IVF after 40, her doctor should always discuss the risks of getting pregnant after 40.

Getting Pregnant at 40: Risks to Consider

Some examples of heightened pregnancy risks at 40 and after include:

• Women who are pre-diabetic are very likely will become outright diabetic during pregnancy (so-called gestational diabetes);
• Borderline hypertension often leads to hypertension in pregnancy, including preeclampsia/eclampsia;
• Women with cardiac problems run the risk of seeing their hearts decompensate, leading to congestive heart failure; autoimmune diseases, while usually mostly improving during pregnancy, at a very high likelihood flare at the end of pregnancy and, especially, in the postpartum period; and
• Spinal problems, like lower back pain, often get much worse in women pregnant at 40 because pregnancy hormones loosen ligaments, thereby increasing the chances of disc problems.

In addition, maternal medical problems during pregnancy, of course, can, and in most cases will, affect pregnancies: Having to go through surgery uniformly increases the risk of premature labor; practically all significant medical problems, indeed, are associated with increased risk for premature delivery, including hypertensive disease of pregnancy, cardiac diseases and, of course, autoimmune diseases. The prevalence of all medical problems increases with the advancing female age.

Pregnancy Risk after 40

It’s important to choose a fertility clinic that understands the risks of pregnancy at 40 and beyond. Watch as Dr. Gleicher explains what women over 40 getting pregnant should discuss with their doctor.

Managing a High-Risk Pregnancy After Age 40

All of this, however, does not mean that older women should not get pregnant. It also does not mean that all women with known medical problems should be refused fertility treatments. On the contrary! Referring to almost all medical problems, studies have clearly demonstrated that most women can safely go through pregnancy if they are properly prepared and properly monitored during pregnancy and into the postpartum period (there are exceptions, of course, and there are a limited number of medical conditions where pregnancy is clearly contraindicated). But this also means that women getting pregnant after 40 must receive individualized diagnostic workups before conception that go beyond their fertility problems. In other words, in CHR’s opinion, the fertility center’s responsibility is not only to help older patients conceive, but also to ensure that their pregnancy will be as uncomplicated as possible.

The risks of pregnancy after 40, of course, apply whether an older woman conceives with her own or with third-party donor eggs. The “stress” on the mother’s body remains the same, though immunological problems in pregnancy--for example, preeclampsia, and premature deliveries--may, indeed, be further enhanced in donor egg cycles since the maternal immune system now must deal not only with a 50% semi-allograft but a 100% complete allograft.

Pregnancy in older women in their late 40s and early 50s, in summary, is clearly riskier than at younger ages. Most older women can, however, still be safely managed through pregnancy.

Having a Baby after 40: Risks and How to Manage Them

It’s best to consider how you’ll manage the risks of pregnancy after 40 before you become pregnant. The following tips will help you work with your doctor, whether a reproductive endocrinologist or a regular OBGYN, to successfully navigate the risks of having a baby after 40:

1. If at all possible, potential medical problems should be identified in advance, so that patients can be proactively placed under appropriate medical co-management by specialists. Proactive management is always preferable!
2. Patients must also be informed that neonatal complications increase in parallel with advancing age, though those in a large majority can also be satisfactorily addressed with proper proactive pregnancy management.
3. Older patients should automatically be advised that their pregnancy will, therefore, be considered relatively high-risk and should be delivered in a tertiary-care hospital, with appropriate maternal and neonatal services available to manage complicated pregnancies and their offspring.
4. More so than younger patients, older women also must be more carefully monitored into the postpartum period, with some pregnancy-associated complications manifesting themselves up to 4-5 months postpartum.
5. There are women who should no longer go through pregnancy and such women should be strongly discouraged from attempting pregnancy. These cases are rare and mostly include women with cardiac problems, like decompensating valvular heart disease, pulmonary hypertension, Eisenmenger syndrome, and prior myocardial infarction (as recently reported, an increasing cause of the rising U.S. maternal mortality rate).
6. At the same time, the management of medical problems in pregnancy is constantly improving. A good example is HIV, which at one time was considered an absolute contraindication for pregnancy but today, in most instances, is no longer a barrier to normal and healthy delivery. An even more remarkable example is diabetes, which before insulin became available for treatment, was characterized by extremely high pregnancy loss rates. Diabetic women, indeed, rarely ever delivered. Nowadays the pregnancy outcomes of diabetic women having a baby at 40, and their risks are hardly different from those of non-diabetic patients.

Speak to Your Doctor if You’re Concerned About Your Pregnancy Risks Over 40

If you are trying to conceive and are curious about the risks of having a baby after 40 and how to manage them well, our specialists at the Center For Human Reproduction have decades of expertise in helping women in their 40s and 50s get pregnant and have healthy pregnancies through proactive risk management. Feel free to contact us with any questions or concerns.