Pregnancy after 35


Shieva Ghofrany: [00:00:00] We are gonna discuss pregnancy after 35. Um, you guys have probably heard this term if you're over 35, or it might be looming because you guys feel like this is a looming age, which, um, bums me out because it is not an age after which your risk exponentially goes up for anything but the terms geriatric pregnancy and advanced maternal. 

Which I find really yucky and onerous, and yet unfortunately people, we live in a world, especially as medical doctors, where you, the public, has asked. We, the medical doctors, us the medical doctors, um, to be accountable. And so that means we have to have like rules and protocols. So please do not be angry with your doctors if you see those labels. 

I don't tend to use those labels because I kind of instead would say to a patient, all right, here's what we need to do. In your particular case, we're gonna do X, Y, Z. But it is not wrong. so that everyone kind of extrapolates the same information to use those terms. Ama advanced maternal age. Okay, so let's just get that out there. 

So advanced maternal age is women over [00:01:00] 35. Technically. I'm gonna talk about a little, couple things that you need to do if you're over 35, and then why I think that term has become so onerous to people. So over 35, which is a huge number in our population of all the babies we've delivered. I don't know what percentage someone could do the math if someone had the time. 

But it's a huge number because in our population we tend to have a lot of very educated women. Gotten married later, started their careers first, therefore delayed their childbearing, and so they're over 35. I myself was 34, 38 and 40 when I had my babies, in fact, almost 41 when I delivered my third one. 

So what are the concerns and risks? Well, one is just that getting pregnant is slightly harder. The older we get, having chances of things like down syndrome. I don't like to say risk cuz that sounds terrible because. Many, many, many people embrace Down syndrome as just a, a different, um, child. It's not a risk. 

So again, the chance of getting pregnant goes down a little bit as we age, the chance of things like chromosome differences, like Down syndrome go up the chance [00:02:00] of things like blood pressure and diabetes go up. Okay. So those are the objectives. Unfortunately, the objective data shows that there is a slightly higher chance of things like stillbirths as we get older, probably because of the issues. 

Underlying diabetes or high blood pressure, none of those risks jumps exponentially. So in fact, if I were talking to a 25 year old who said, oh my God, is my risk terrible at 25, I should let technically say your risk at 25 is slightly lower than your risk at 26. Now, we don't say that because we just don't say it because her risk is generally low, but again, each year, Our risk of miscarriages and our chance of getting pregnant changes year by year by year, slowly, slowly, not exponentially, even from 34 to 35, it does not jump exponentially. 

What the, what 35, um, meant for us as a strict line cutoff as doctors was that back in the day over, let's say 10 to 15 years ago, we didn't have that blood test that many of you have heard of called the Cell-Free [00:03:00] dna. It's a blood test. You can do it after eight to 10 weeks. It tells you what the chromosomes of the. 

And it tells us that the chromosomes are considered the normal number that we should have, which is 46 chromosomes. Or it tells us a variant. It will tell you if it's a boy or girl if you wanna know, but that's not the purpose of the test. Right. So that blood test was developed, I'm guessing, I don't know, 10 ish years ago. 

Prior to that, the only way we could say for sure if a baby had a chromosomal issue was by doing an amniocentesis. Hear me out on this one with a net math, because this is where 35 became this very dirty word. If you. Under 35, the chance of having a baby with a chromosome abnormality was, let's round out the numbers, about less than one in two 50. 

Your chance of having a miscarriage if you have this amniocentesis test was slightly higher than one in two 50, so hear me out on the amnio. The amniocentesis, if you don't know, is where the doctor typically in our area, a perinatologist, meaning a subspecialist who does [00:04:00] this all the time. So their risk is actually very small, but we quote the general risk, which. 

That needle goes into the uterine cavity, it removes fluid, it gets sent to the lab and the lab. People look at the actual chromosomes and they say, look, the baby has the normal number of chromosomes, or not that risk of miscarriage, which we deem to be about one in two to 300. Those are a little bit old fashioned numbers, but that's what's still published. 

So again, if you're under 35, the risk of a miscarriage from the am. Was higher than your risk of actually potentially having a baby with Down Syndrome. Therefore, you were not recommended to have an amnio the minute you hit 35, your risk of the baby having Down Syndrome was slightly higher than the risk of a miscarriage from the amnio. 

Therefore, you were encouraged to do the amnio. So it was literally that line. Merely because of the risk of miscarriage from the amnio. Does that make sense? With that legions of women to this day will say, oh my God. Like I'll literally have women who are 34 and they're like, I have to have a baby [00:05:00] now cause I have to have a baby before I'm 35. 

Ladies, your risk does not jump exponentially. If you wanna have a baby before 35, then have a baby before 35. But if you don't, please don't feel like you immediately need to just because of some false line that was drawn in the sand for legitimately good, um, academic medical reasons, but should not make you think falsely that your risk jumps. 

Okay? So first of all, does that make sense? So like we talked about, Chance of getting pregnant goes down slightly each year. Chance of things like chromosome abnormalities goes up slightly each year. Those are two objectives, but it's slightly each year separately. There is data about women over 35 with regard to things like hypertension, diabetes, and again, all of this goes up slightly, slightly, slightly. 

But in our world we have to have lines that we draw. So the line was drawn that if you're over 35, the newest data shows you should be taking a baby aspirin. Baby aspirin is a misconception cuz babies in fact cannot take aspirin because it's very dangerous for them. Um, but baby aspirin, back in the day when we used to give babies aspirin, which was prior to [00:06:00] my life, I think, um, we used a small dose, 81 milligrams. 

So in America we call it baby aspirin, but it's really 81 milligrams of aspirin and you should. Baby aspirin if you are over 35, there's a whole list of reasons we would give baby aspirin nowadays. If you have twins, if you have hypertension, if you have diabetes, if you had a previous baby that was born because of severe preeclampsia. 

Um, those are the ones that I can think of off the top of my head if you're the extremes of age. In fact, very young women who have never had a baby, like an 18 year old who's never had a baby, that's the newest guideline. She should even take it, but certainly. 35 and older are encouraged to take baby aspirin. 

And this is a new enough guideline that not all doctors stick with it. And I don't think they're wrong. And I offer it to our patients, but I certainly don't make it imperative if they otherwise don't have any risk factors. In other words, a lean, healthy woman without high blood pressure, diabetes, twins, multiple miscarriages, things like that. 

If she's 35 and she doesn't wanna take a baby aspirin because it's the newer guideline, I wouldn't force her to. Um, that said, I took baby aspirin in all my pregnancies, and I think it's not a bad idea. So [00:07:00] that's one objective. You're 35 or older, you'll be offered slash encouraged to take baby aspirin. 

Some doctors will stick with some of the AMA guidelines that would say that if you're over 35, we should encourage you to deliver at 39 weeks as opposed to going. Past 39 or 40 weeks, or even 41 weeks, that we would let the general population because of the slightly higher risk of stillbirth. Um, do I think that recommendation is good or bad? 

I think it's very individual. Meaning if I have a patient who really wants to be induced, I at least have a legitimate reason. If she really doesn't wanna be induced and she's being watched carefully, then I think it's absolutely appropriate and fine to let her go to 41 weeks. But, My choice. That is not the rule. 

In other words, you should talk to your doctor. Um, and if your doctors do have that hard, fast rule, about 39 weeks, again, they're not wrong. Don't malign them. There is data to support them. So, That's another second. Um, and those are really the two big ones I can think of, right? So again, what I remind patients of, I have many 39 year olds who are lean and healthy and exercise and [00:08:00] don't have any objective risk factors, but for their age they will probably do better than a 23 year old that I might have, who is unfortunately. 

Very overweight or hypertensive or diabetic or smokes or any of those things, right? So age is only a number, unfortunately, is a number through which we have to look at certain things. But again, are you at risk if you're 35? My answer is no. My answer is I'm not gonna label you. My answer is because you're 35 or over. 

There are certain things we're going to discuss, and by the way, getting back to the amnio versus the cell-free dna, again, practices behave differently, but what I usually tell patients is I don't care if you're under 35 or over 35 with regard to the test. I care what you would do with the information. 

In other words, I do not offer the cell-free dna, the blood test that tells us about Down Syndrome to only women who are over 35, because I might have a 22 year old who says, you know what? The answer about whether or not my baby has Down Syndrome very much matters to me either because I [00:09:00] would consider stopping the pregnancy or because I just need that information before I deliver, as opposed to a 49 year old who might. 

Even though my, my chance is much higher of Down syndrome, I don't care. It's not gonna matter. I'm not gonna do anything differently and I don't need that information ahead of time. So again, for me, , I don't care what age you are with regard to whether or not you're gonna do those tests. I care what you would do with that information. 

And if you would do something with the information, then by all means do that blood test. Your insurance may or may not cover it, but they cap those costs at a fairly, I hate to say low because this is not a loan number for everyone, but usually they'll cap that cost of that test at about two to $300, even for women or under 35 if your insurance doesn't cover it. 

Um, okay. I hope all that makes sense and. Peace out. It's my Tuesday and I'm gonna go do some fun stuff with some friends and then do some work. And then I have this speech I'm giving, well it's not a speech, it's an interview talking about fear and getting rid of fear. So it's [00:10:00] tonight. Um, thank you for those of you who are coming, if you live in the area, for those of you who are not living in the area or couldn't get tickets because it sold out, I am hopefully gonna tape it. 

So I'll try to put some snippets on later. Okay. Bye-Bye.