Exploring preconception, prenatal, and postpartum care for patients in their 50s

Exploring preconception, prenatal, and postpartum care for patients in their 50s | Image Credit: © Natalya Lys - © Natalya Lys - stock.adobe.com.

Over the past decade, the overall birth rate in the United States has declined.¹ However, the birth rate in people aged 45 to 49 years at delivery has risen 12% in recent years, as it has in people 50 years and older.^2,3 Since at least the 1970s, a pregnant person aged 35 or older has been categorized as being of advanced maternal age (AMA). This age was chosen based on data demonstrating a decline in fertility and an increased risk for genetic anomalies in people 35 years and older at the time of delivery.⁴ Yet data from newer studies indicate no single age at which the risk of pregnancy changes. Rather, as age at the time of pregnancy increases, the potential risks do too.^5-7 A subset of AMA has emerged: the parturient of “very advanced maternal age (vAMA),” or patients who are 45 years at delivery. However, increasingly, studies are grouping pregnant individuals into categories of 5-year increments: 35 to 39 years, 40 to 44 years, 45 to 49 years, and 50 years and older. The focus of this discussion will be those at the current upper limit of parturition–people who are 50 years or older at the time of delivery.

Although the average childbearing age has markedly risen, it is important to note that the absolute number of people choosing childbearing in their 50s remains low. In 2022, the birth rate for individuals aged 50 to 54 years was 1.2 births per 10,000 individuals in the United States, up from 1.0 in 2021. That year, 1230 births were to individuals aged 50 and older, up from 1041 in 2021.² In comparison, in 1997, the number of births in this age group was 144. The first reported case of an “elderly obstetrical patient” was written in 1917, and although the incidence of pregnancy in this population is going up, publications on this topic remain sparse.⁸ This article will review suggestions for optimal prenatal, labor and delivery, and postpartum care for peopleindividuals who choose to become pregnant in their 50s.

Preconception

The discussion about pregnancy later in life cannot be had without first acknowledging that this would often not be possible without the advancements in reproductive technology, specifically oocyte donation and in vitro fertilization (IVF). In fact, it was not until the 1990s that individuals over 40 years old were accepted as donor oocyte recipients.⁹ Much of the reticence may have stemmed from the question of whether an “aging uterus” can provide a receptive environment for embryo implantation and development.¹⁰ Evidence from animal studies has demonstrated that the uterus has decreased hormonal responsiveness as it ages.^11,12 For humans, nomenclature exists for ovarian aging in the context of defining menopause; however, there is no analogous definition for when a uterus may be considered unable to support a pregnancy.¹³

In the 1990s, a group of reproductive endocrinologists sought to assess whether menopausal individuals aged 50 to 59 years could become pregnant with the assistance of IVF.^9,10 This was considered a reasonable investigation, given evidence that uteruses of “older individuals” respond to hormone replacement therapy, with the authors identifying the primary barriers to postmenopausal conception as being the “physical and psychological health of potential recipients.” The devised protocol included the following medical screenings: stress treadmill electrocardiography (EKG), mammography, chest radiography, glucose tolerance test, fasting serum insulin, fasting cholesterol and lipoproteins, compete metabolic panel (CMP), prothrombin time/partial thromboplastin time, thyroid stimulating hormone (TSH), complete blood count (CBC), and Papanicolaou test. Participants also underwent infectious disease screening (HIV, syphilis, hepatitis) as well as a reproductive workup (transvaginal ultrasound, hysterosalpingogram, endometrial biopsy on hormone replacement, hamster egg penetration test, and partner semen analysis). Finally, 2 independent psychologists interviewed each couple. In this cohort, 8 patients became pregnant; 1 patient underwent a miscarriage, and, at the time of publication, only 3 had delivered, and 4 had ongoing pregnancies.¹⁰

Since this study was completed, findings from several larger case series have been published on the reproductive outcomes of pregnancies in individuals 50 years and older.^10,14-16 Although details of the exact preconception medication and psychological evaluations vary in each study, in general, individuals 50 years and older planning to use IVF to conceive were required to undergo the following: treadmill stress test, mammogram, chest radiography, EKG, Papanicolaou test, CBC, CMP, lipid panel, TSH, and infectious disease workup.^14,16 One study protocol also required participants to start with a simulated cycle to confirm endometrial response to exogenous estrogen and progesterone.¹⁵ Several authors also mentioned the requirement for psychological evaluation, with goals ranging from emphasizing “issues of parenting and child support” to “identifying potential issues due to unequal genetic participation in anticipated offspring…[and] disclosure to [the] child of his/her genetic background.” ^14,15 Some providers recommended a maternal-fetal medicine consult prior to conception to review the risks of pregnancy in advanced age, but this was not a uniform recommendation.

The American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine, and American Society for Reproductive Medicine (ASRM) all fail to provide specific guidance for preconception counseling or evaluation in those older than50 years who wish to become pregnant. For all patients, these societies jointly recommend a review of medical, surgical, and psychiatric histories; an assessment of substance use and exposure to violence; and an evaluation of genetic risk, immunization and nutritional status, physical activity, and teratogen exposures.^17,18 In 2016, the Ethics Committee of ASRM published an opinion stating that although oocyte donation has made pregnancy possible at more advanced maternal ages, embryo transfer should be “strongly discouraged or denied” to individuals with underlying conditions that increase or worsen obstetrical risk (such as diabetes or hypertension).¹⁹ Additionally, this committee opinion suggests that due to the potential complexities of pregnancy at older ages, as well as concerns about longevity, pregnancy in individuals older than55 years should “generally be discouraged.”¹⁹

Although this committee opinion is a suggestion, nationally, many reproductive practices adhere to guidelines put forth by ASRM. If a person who requires assisted reproductive technology (ART) presents for preconception counseling, she should be made aware that finding a reproductive endocrinologist may be challenging, regardless of her current state of health.

Prenatal care

Although the ACOG Practice Bulletin “Pregnancy at Age 35 Years or Older” suggests that pregnancy in this age group be considered at higher risk for adverse maternal, fetal, and neonatal outcomes, the quality of evidence backing this statement is low.²⁰ Traditionally, it has been assumed there is a linear relationship between advancing age and the rate of complications. Data from several studies, specifically in this cohortolder than 50 years, confirm that there are often higher rates of complications, but a linear correlation was not seen. Patients should be aware that if they choose to pursue pregnancy in AMA, they may be at higher risk for miscarriage or intrauterine fetal demise,^21-23multiple gestation,^10,15,22,24 aneuploidy,⁴ gestational diabetes,²⁵ hypertensive disorders of pregnancy,¹⁵ preterm delivery,^24,26 and low birth weight.^24,27 Additionally, findings from 1 study showed that over 30% of pregnant people aged 50 and older require antenatal hospitalization.²⁷ The likelihood of experiencing perinatal complications is roughly 30% to 45%, depending on the study reviewed.

Interestingly, in contrast, data from a case series of 7 individuals aged 51 to 59 years, all of whom conceived spontaneously, showed that all had pregnancies without significant perinatal morbidity or mortality.²⁸Of note, this specific study is less generalizable to the US population; the median parity was 9, and people were immigrants of low socioeconomic status who had never used contraception.²⁸ According to data from all other published studies on this topic, patients used IVF to conceive. Although ART alone may partially contribute to the increased rate of maternal morbidities seen in the population older than 50 years, it could also have been a protective factor in that all individuals undergoing IVF were required to undergo rigorous preconception screening. This may have eliminated people whose at higher risk for complications of pregnancy. Even when complications were seen, pregnancy appears to have been largely successful.^10,14,16 That said, it is challenging to make recommendations given that all studies in this population are small, and it is possible that studies were not powered to detect differences for rare maternal morbidities.

Even less data exist on the psychological implications of pregnancy and parenthood at ages above 50 years. Individuals pursuing pregnancy at AMA often express more worry about dying during pregnancy, birth defects, or having newborns who require admission to a neonatal intensive care unit.^29-32 Yet, findings from several studies suggest that delaying childbearing may be a psychological advantage in that older mothers report they feel more prepared, resilient, secure, and competent entering motherhood at a more advanced age.^29,31-33

Nevertheless, this does not mean that advancing maternal age as a risk factor for adverse perinatal outcomes should be ignored. As the quality of data is not strong, ACOG does not offer much specific guidance on whether or how to alter prenatal care for the vAMA cohort. However, several areas exist in which care recommendations are different for AMA patients, and these may be extrapolated to this population. For example, given that starting aspirin 81 mg a day between 12 to 16 weeks’ gestation is recommended for individuals older than 35 years who are at increased risk for preeclampsia, this is a reasonable practice to adopt in patients older than 50 years.³⁴ Additionally, due to the increased risk for growth abnormalities, third-trimester ultrasound growth assessments are recommended.³⁴ In pregnant patients older than 40 years, the risk of intrauterine fetal demise (IUFD) has been shown to increase between 33 to 34 weeks’ gestation and continue until 39 weeks’ gestation and beyond.^35,36 In light of this, most studies initiate weekly antepartum fetal surveillance between 32 to 36 weeks’ gestation.^37,38Little guidance exists on the “safest” mode of delivery for pregnant individuals older than50 years. The limited literature indicates that the majority of individuals in this situation undergo elective cesarean delivery, or it is recommended based on medical or surgical histories.^{10,14,24,28,39-41} Although there are no data to suggest that delivery is indicated at less than 39 weeks unless other medical complications arise, given that the risk of IUFD is known to increase beyond 39 weeks in AMA patients, delivery at gestational age is recommended.³⁵

The lack of specific guidance for patients older than 50 years likely reflects the small number of pregnant people in this group.^15,42 Evidence from most studies demonstrates that pregnant individuals at this age typically do well with a standard of care similar to that for individuals between 35 and 49 years.

Postpartum

From a physiological perspective, a postpartum patient 50 years and older without chronic medical issues should recover similarly to a patient younger than 50 years. Yet the physical recovery from childbirth is perhaps easier than the adjustment to new parenthood. Many of the IVF protocols used in this patient population require patients to have a psychological evaluation prior to undergoing fertility treatments. Providers often cite the desire to use these sessions to identify “potential issues due to unequal genetic participation” and concerns about “adjustment to parenthood at advanced parental age.”^10,15 Yet less data exist on how these parents and children fare after delivery.

As mentioned previously, individuals entering pregnancy at an advanced age express more concern about the risks associated with pregnancy and childbirth;^30-32 however, results are mixed as to whether AMA is associated with major depression after delivery.⁴³ Although evidence from some studies fails to show an increased incidence of postpartum depression and stress, other evidence suggests there may be significant differences between older and younger pregnant people’s adaptation to parenthood.^29,43-45 Absence of support, being a non-English speaker, having preexisting depression, or having a child in poor health or with a challenging temperament may be more significant contributors.^43,46 In fact, many mothers report feeling that being of an advanced age can be an advantage in that individuals in their circles often are already parents and can offer insight and assistance.⁴⁷ Additionally, older mothers often report feeling better prepared to care for their newborns, with parenting styles observed to be supportive and close.⁴⁸ Of note, most of these studies did not account for the impact of maternal socioeconomic status (SES) or education level. When this was factored in, being of higher SES and having more education were protective against poor maternal or neonatal psychological or developmental outcomes.²⁹

Although there may be benefits to waiting to become a parent, it is essential to acknowledge the unavoidable reality that the average life expectancy in the United States is only 76.1 years.⁴⁹ There is a greater likelihood that children of older parents will experience the loss of a parent earlier on in their lives. Before patients start the journey to conceive, physicians should discuss the support systems in place that can assist with caring for children if the parents are no longer able to do so.

Conclusion

Pregnancy at 50 years and older remains infrequent, although it is becoming more common. Nevertheless, data are scant, and it is challenging to make statements regarding standards of care. Although data from several studies demonstrate that pregnancy complications are not more prevalent in this cohort, there are also data demonstrating increased incidences of several adverse perinatal outcomes. Currently, the ASRM Ethics Committee opinion of oocyte or embryo donation to individuals of advanced age discourages pursuing embryo transfer beyond the age of55 years; however, the opinion also recognizes that older men can spontaneously father children at much older ages, and denying ART to individuals at equivalent ages may be prejudicial.¹⁹ As advancing reproductive technology has made pregnancy in individuals 50 years and older achievable, this phenomenon is unlikely to disappear in the foreseeable future. Therefore, it is crucial to familiarize oneself with current suggestions on safely managing these patients. Pregnancy can be the ultimate stress test on the body. Thus, as is true for every woman considering pregnancy, and especially those aged 50 and older, patients should optimize their health before attempting conception, and they should receive comprehensive care, including management by the maternal-fetal medicine department.

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