Evidence-based management of women of advanced maternal age

Abstract

The average age of women at childbirth in industrialised nations has been increasing steadily for approximately 30 years. Women aged 35 years or over have an increased risk of gestational hypertensive disease, gestational diabetes, placenta praevia, placental abruption, perinatal death, preterm labour, fetal macrosomia and fetal growth restriction. The risk of trisomy 21, 18 and 13, and other sex chromosome aberrations (e.g. Klinefelter syndrome) increases significantly with maternal age, especially in women aged 35 years and older but there is no age-related association with an increased risk of triploidy or monosomy X. Unsurprisingly, rates of obstetric intervention are higher among older women. Of particular concern is the increased risk of antepartum stillbirth at term in women of advanced maternal age. In all maternal age groups, the risk of stillbirth is higher among nulliparous women than among multiparous women. Women of advanced maternal age (>40 years) should be offered low dose aspirin (in the presence of an additional risk factor for pre-eclampsia) and offered serial ultrasounds for fetal growth and wellbeing; given the increased risk of antepartum stillbirth, induction of labour from 39 weeks’ gestation should be discussed with the woman. In very advanced maternal age (≥45 years of age), women who conceived via in vitro fertilization are significantly at increased risk of preterm delivery and adverse maternal outcomes compared to those who conceive naturally.