Babies After 40: The Hidden Health Risks of Mid-Life Pregnancy
From Health magazine
After years of struggling with repeated miscarriages and fertility treatments, including in vitro fertilization (IVF), Joanna Brody was thrilled when she finally conceived on her own at the age of 43—even considering the increased risk of health problems associated with pregnancy after age 40. Still, the former marathon runner was in good health and exercised throughout her pregnancy, which was uneventful.
But two days after returning home from the hospital after her daughters birth (she also had a 6-month-old adopted son), she woke up feeling like she couldnt breathe. “I thought I was having a panic attack due to the stress of taking care of two infants while building a new home,” Brody, now 45, recalls.
The next day, when she couldnt catch her breath walking up a flight of stairs, she rushed to the emergency room. There, doctors discovered that her lungs were filled with fluid, a sign of peripartum cardiomyopathy, a potentially fatal condition that occurs when theres damage to the heart, resulting in a weakened heart muscle that can't pump blood efficiently. While it occurs in only about 1 in every 1,300 deliveries, its most common in older women, especially those, like Brody, who are over the age of 40.
The number of women giving birth into their 40s and 50s and beyond is at record highs, according to the Centers for Disease Control and Prevention. In 2007, 105,071 women aged 40-44 gave birth, the highest rate since 1968; the birth rate for women 45 to 54 was 7,349, an increase of 5% in just one year.
“The numbers have really skyrocketed over the last two decades, as research has increasingly shown that older women are able to carry pregnancies and deliver babies safely,” says Mark Sauer, MD, chief of reproductive endocrinology at Columbia University Medical Center and a leading researcher in this field.
Theres no official data on how many American women over the age of 54 successfully give birth each year, although there have been plenty of news reports of women in their late 50s and early 60s who have conceived via donor eggs. While older moms have long been the source of biblical legend (think of Sarah, who is said to have given birth to her husband Abrahams son Isaac at the jaw-dropping age of 90), right now the oldest documented birth mother in the world is Omkari Panwar, a 70-year-old Indian woman who gave birth to 2-pound twins in 2008 via emergency cesarean section.
But the United States has had its share of 60-plus new moms, too, including Frieda Birnbaum of Saddle River, New Jersey, who in 2007 at age 60 set the record for the oldest woman in the country to give birth to twins. (A 62-year-old, Janise Wulf, gave birth to a singleton in 2006.)
While it may seem nothing short of miraculous that cutting-edge IVF technology is enabling older women to get pregnant, experts are concerned about the increased risk of maternal health problems, ranging from cardiac complications to potentially even a higher risk of developing breast cancer.
“A healthy 42-year-old with no medical problems who is in good physical shape and conceives naturally is likely to have just as nice a pregnancy as a woman who is a decade younger,” says Laura Riley, MD, a maternal-fetal-medicine specialist at Massachusetts General Hospital and chairwoman of the communications committee of the Society of Maternal-Fetal Medicine. “But there are a fair number of women in their mid-40s getting pregnant through IVF who have a ‘touch of hypertension, are a little overweight, or are prediabetic, and that's where we start running into problems.”
Older women are increasingly at risk for potentially deadly complications. A 2002 University of Southern California study, for example, found that 26% of women ages 50 to 54 suffered from preeclampsia (a life-threatening condition characterized by high blood pressure and protein in the urine), and 13% developed gestational diabetes (a temporary form of diabetes that occurs during pregnancy)—and that number soared to 60% and 40%, respectively, for those over the age of 55.
While there are no official guidelines from organizations like the American Society for Reproductive Medicine on how old is too old, leading fertility experts and high-risk obstetricians are voicing concerns about this brave new world of peri- and postmenopausal pregnancy.
“The age cutoff at our clinic is 54, based on the research that shows a marked increase in complications in women older than 55,” says Richard Paulson, MD, director of the Fertility Program at the University of Southern California Keck School of Medicine and one of the countrys leading researchers on pregnancy in the peri- and postmenopausal years.
Others are more conservative. “We have an age cutoff in our practice of 44 years of age for someone using her own eggs and 51 years of age in someone using donor eggs,” says Robert Stillman, MD, medical director of Shady Grove Fertility Center, one of the countrys largest fertility clinics, with 15 offices in the Washington, D.C., area. “Weve never had a successful birth in a woman over the age of 44 using her own eggs, and we think its unethical to promote treatments in a vulnerable population where theres not a chance of success. We won't treat women over the age of 51, period, because we believe there are too many risks involved with carrying the pregnancy, both for the mother and for the fetus.”
But many clinics across the United States—including some of the nations leading fertility centers—take women who are well into their 50s. So what are these risks, and what exactly do they mean for older women who are contemplating pregnancy? Here, a look at the biggest dangers.
The risk of cancer
One can't help thinking of Elizabeth Edwards, who gave birth to two children at ages 48 and 50 after undergoing fertility treatments—and who was diagnosed four years later, in 2004 at the age of 55, with stage II breast cancer. (In 2007, she revealed that her cancer had recurred and was now at stage IV.)
While she has never publicly discussed whether there could be a link between fertility treatments in older moms and subsequent breast cancer, breast cancer experts speculate that the two could be related.
“Its a very unsettled question,” says Julia Smith, MD, PhD, director of the Lynne Cohen Breast Cancer Preventive Care Program at the New York University Cancer Institute. “Every time weve tampered with the natural cycle of reproductive hormones, weve had a problem, as evidenced by research showing a link between hormone replacement therapy and breast cancer. As women get older, theyre at increased risk for breast cancer, and Im concerned about giving peri- or postmenopausal women additional sex hormones that could disrupt the natural course of aging of the breast cell.”
Research also shows that older women who have recently given birth are more likely to develop breast cancer in the 15 years following the birth than their peers of the same age who have never had children. One Swedish study followed women after theyd given birth and found that the childbearing women were slightly more likely to be diagnosed with cancer—and women who had their first child after the age of 35 had the highest risk, about 26% higher than women who had never given birth. (This is a transient risk: After 15 years, their odds dropped below that of women who had never given birth.)
“My worry is if an older woman is cooking a really early breast cancer and then is exposed to massive levels of estrogen during her pregnancy, could that accelerate tumor growth?” adds Mary Jane Minkin, MD, professor of obstetrics and gynecology at the Yale School of Medicine. “No ones ever studied it, and its a real possibility.”
The other point of concern: “The minute a woman gets pregnant, we can't screen her for breast cancer. And we can't do a mammogram until she's finished breast-feeding, which could be almost two years later,” Dr. Smith points out. “If she's younger than 40, its not a big issue because her overall risk of breast cancer is so low. But if she's 45 or 50, then Im worried.”
Cancer experts are less concerned about the risks of other types of reproductive cancers among past-40 women undergoing fertility treatments. In fact, a Danish study published in February in the British Medical Journal followed more than 50,000 women who underwent fertility treatments for 15 years and found no increased risk of ovarian cancer among women who took most types of fertility drugs.
The one exception—women who took clomiphene citrate (Clomid) had an increased risk of a type of ovarian tumor called serous ovarian tumors, which may be more influenced by hormones than other tumors, says Louise Brinton, PhD, chief of the Hormonal and Reproductive Epidemiology Branch at the National Cancer Institute. Brintons own preliminary research has found a possible link between Clomid and endometrial cancer, a treatable cancer of the womb. “Many women in their 40s and 50s are using donor eggs, so they won't be taking Clomid, which is an ovulation-inducing drug,” she points out. “But for those women who are, they need to be aware that there may be a link.”
The problem is, many women aren't briefed by their doctors on potential long-term risks. “I talk to fertility specialists all the time and bring up my concerns, and they tell me the same thing they tell their patients—they dont have any evidence that it is harmful,” Dr. Smith adds. “But its not a question of not having evidence proving harm—we dont have any evidence proving safety.”
The risk to your heart
The strain of pregnancy, experts say, can be likened to the stress of running a marathon—and the older a woman is, the more likely she is to have complications from it.
Doctors of women in the 40-plus set are most concerned about pregnancy-induced preeclampsia, which generally surfaces in the third trimester. While the incidence of preeclampsia among all moms-to-be is 3 to 4%, that risk increases to 5 to 10% if you're older than 40 and jumps up to 35% if you're past 50. Most reputable fertility clinics require patients over the age of 45, especially those with borderline cholesterol or high blood pressure, to undergo more extensive cardiology screening, like an electrocardiogram (EKG) or a stress test, but “these tests can miss women who have borderline heart disease,” Dr. Stillman says. “Sure, they may be fine playing tennis. But the stress of nine months of pregnancy? That's the equivalent of climbing Mt. Kilimanjaro.”
In addition, pregnancy can prompt an earlier onset of health problems that would have otherwise developed later in life. “A 50-year-old woman with borderline high blood pressure who might not develop hypertension until she's 60 may start to have it during her pregnancy,” explains Errol Norwitz, MD, a high-risk OB-GYN at the Yale School of Medicine. And this can set her and her baby up for a host of complications.
Deborah Lake, 50, developed preeclampisa seven years ago (she was 43) while carrying twins, prompting her physician to induce labor. “My blood pressure had always been quite low, but toward the end it began to creep up to the point where my doctor decided to induce me at 36 1/2 weeks,” she recalls. Lake delivered her first daughter, Savannah, vaginally. But her second daughter, Courtney, got stuck in the birth canal, prompting an emergency C-section. Lake was discharged after three days, only to return a few days later when her blood pressure shot up and her whole body swelled, both signs of preeclampsia. “They gave me diuretics, and I peed out about 50 pounds of water weight in three days,” she recalls.
Lake had been trying to get pregnant for almost a decade and finally conceived via donor eggs. “Because of my age and the fact that I was carrying twins, I was so careful—I ate perfectly, I didnt gain too much weight,” she says. “But even that, ultimately, wasnt enough to stave off problems.”
There are also heart concerns after pregnancy. “Most women tend to gain weight with each pregnancy and keep those extra 10 pounds around for a while,” Dr. Minkin says. “That extra weight increases an older womans risk of developing heart disease.”
Progesterone, a reproductive hormone that's given to women during IVF and is also present at high levels during pregnancy, causes both blood pressure and cholesterol to temporarily go up, adds Nieca Goldberg, MD, director of the New York University Womens Heart Center. “This isnt an issue for a healthy woman with no risk factors for heart disease.
Peripartum cardiomyopathy, which Joanna Brody had, is also a potential danger among this group of moms. While Brody emerged unscathed, this condition can cause heart failure—which leads to death in 25 to 50% of cases, according to the National Institutes of Health.
Another huge worry: gestational diabetes, a temporary form of diabetes that occurs during pregnancy. It almost always goes away after delivery, but it can be a harbinger of diabetes later in life and puts women at risk for delivering a too-large baby (macrosomia).
Though the overall rate of gestational diabetes is 3%, it rises to 7% in women older than 40 and 20% in women older than 50. But while risk factors like a family history of diabetes, borderline blood sugars, being overweight, or having had gestational diabetes in an earlier pregnancy all increase your chances of getting it, many older women with none of these end up developing this dangerous condition.
Not surprisingly, because over-40 women are more at risk for a variety of health problems, their C-section rate is significantly higher than that of younger moms. Almost a third of all women in the United States deliver via C-section, but almost 50% of women having their first child between 40 to 45 and almost 80% in women ages 50 to 63 undergo the procedure.
“Older women have older uteruses, which tend to not contract as well, which can result in abnormal labor” and lead to a C-section, explains Robin Kalish, MD, director of clinical maternal-fetal medicine at Weill Cornell Medical Center in New York City.
The risk of placental problems
While placental problems are relatively rare during pregnancy, the risk shoots up once you hit the big 4-0. If you get pregnant past that age, you have a 10-fold increased risk, compared with women younger than 30, of placenta previa—a dangerous condition in which the placenta does not move up and away from the opening of the uterus during pregnancy; this can cause severe vaginal bleeding and activate premature labor. The main reason? An older uterus is less hospitable to the drastic bodily changes of pregnancy.
“The uterus is required to grow from the size of a small pear to a huge watermelon in nine months, which requires an enormous level of blood flow,” Dr. Stillman says. “Vascular disease is ubiquitous as people age, whether its in the heart or in the vagina, and it gets more and more difficult as a woman gets older for her uterus to keep up with the rapid growth of pregnancy.”
Lauren B. Cohen, a New Jersey lawyer who is the second oldest woman in the United States to give birth to twins, at age 59, spent two months in the hospital before giving birth to her twins at 31 1/2 weeks due to complications from placenta percreta, an incredibly rare condition in which the placenta actually breaks through the walls of the uterus and attaches to another organ such as the bladder.
“My doctors said my uterine walls had been weakened, due to age, a past C-section, and the stress of carrying twins,” Cohen explains. During the C-section, she hemorrhaged so much from her placenta that she required a transfusion of 33 units of blood. The twins—born two months premature at just over 3 pounds each—have suffered no long-term health problems, but they have developmental delays.
The risk to baby
Babies born to over-40 women like Cohen are not only more likely to be born early but also more likely to have birth defects. One Columbia University study found that 2.9% of women older than 40 have babies with birth defects, compared with 1.7% of all women younger than 35. Of these, cardiac issues are the most common: Another study found that heart defects were four times more common in infants of women over 40, compared with those age 20 to 24.
“It could have something to do with egg quality or with the fact that older women may have undiagnosed and untreated diabetes or hypertension, which could affect growth and contribute to birth defects,” explains Randy Fink, MD, a high-risk OB-GYN in Miami.
What women must know
While modern medicine is now able to get you pregnant into your fourth, fifth, or even sixth decade, it can't guarantee a smooth and safe road to delivery. There are undeniable health risks to pregnancy in the peri- and postmenopausal years, risks that often aren't revealed to the plus-40 women hoping to get pregnant. If you're in your 40s and considering pregnancy, its critical to be proactive and get a thorough screening to rule out hidden heart disease or diabetes.
“All women in this age group need to get their blood pressure, cholesterol, and blood sugar levels checked, as well as an EKG,” before trying to get pregnant, Dr. Goldberg says. While a borderline or high level on any of these tests doesn't necessarily rule out pregnancy, you'll need to undergo even more detailed tests such as an echocardiogram, which uses sound waves to “see” any potential damage done already to your heart.
Women with risk factors for breast cancer——such as having a family history of the disease——should also think carefully before proceeding, Dr. Smith advises. Most women over the age of 45 are automatically referred to a high-risk practice. If you're not, make sure you get a recommendation for a good one.
The bottom line: It is possible to have a baby in midlife. But before you proceed, its essential to understand the potential dangers to you and your baby.
“Even if a woman passes all the screening tests with flying colors, she's still more at risk for health complications,” stresses Miriam Greene, MD, an OB-GYN at New York University Langone Medical Center. “And we just don't know what the long-term health effects are going to be of all these added hormones on their bodies. If an older woman decides she wants to get pregnant, that's her decision. But she should have her eyes wide open and make sure she's fully aware of all the potential risks.”