FORTY MAY INDEED BE the new 30, but some women are surprised their bodies haven't "gotten the memo" when it comes to having a baby. Women who decide to start a family in their late 30s or 40s often learn even conceiving is out of the question without assistance, and that getting pregnant is only the beginning; older moms-to-be face increased risks of gestational diabetes, hypertension and premature births, among other concerns.
"This is not groundbreaking news: the average age of women getting pregnant for the first time is going up and that can lead to consequences," says Dr. Arthur Zaltz, interim chief of Obstetrics and Gynaecology.
"The older you are, the greater the probability you're going to have the whole gamut of issues."
Dr. Zaltz is quick to point out this demographic has its advantages, too. "The reality is that most of the women in my practice are older, 35 and beyond, and sometimes they are healthier and take better care of themselves than the younger women I look after," he says. "Women who are getting pregnant at a later age are often highly educated, less likely to be smokers or overweight, and are in physically better condition."
To be sure, Sunnybrook – with a $160-million, state-of-the-art Women & Babies space, including the country's most modern neonatal intensive care unit (NICU) and a program focused on high-risk moms – is uniquely positioned to care for these patients should complications arise. Here's how Sunnybrook helps.
A woman's ability to get pregnant naturally begins declining at age 30; that decline speeds up at 35, plummets to about five per cent after 40 and continues dropping. By age 45, according to 2009's Raising Expectations: Ontario's Recommendations of the Expert Panel on Infertility and Adoption, the likelihood of a first-time mom getting pregnant with her own eggs is virtually zero.
"The degree to which a woman's fertility declines after 40 is shocking – and it's a conversation I have with patients daily," says Dr. Marjorie Dixon, a specialist in reproductive endocrinology and infertility at the Sunnybrook-affiliated First Steps Fertility, a staff physician in Sunnybrook's OB/GYN department and co-author of Raising Expectations. She points out that the number-one determinant of success with any type of fertility therapy is the woman's age.
Partnered with Sunnybrook, First Steps has the advantage of being part of a broad spectrum of seamless care, Dr. Dixon says. Patients may first go to Sunnybrook for gynacologic surgery, be referred to First Steps to conceive and then head to Sunnybrook's state-of-the art labour suite again to deliver. Sunnybrook has an arsenal of world-class experts and cutting-edge technologies ranging from obstetricians and specialized gynaecologists surgeons, maternal-fetal medicine specialists, experts in the management of menopause, gyne-oncologists and also fertility specialists.
"Certainly, the assistive reproductive technology has changed our thinking; people are able to get pregnant through those modalities who would not have been able to 40 years ago," says Dr. Zaltz. "Most problems can be dealt with." But both Drs. Zaltz and Dixon urge women to start the conversation long before starting a family is even on the horizon. "And this is to empower women," says Dr. Dixon. "In your 20s, when finishing your education and starting your first job and thinking about buying a home, you need to also have the thought: 'Do I even want a family?' If you do, be proactive about it and be sure the clock isn't ticking faster than you expect it to."
Older women are three times more likely to develop gestational diabetes than their younger counterparts, according to In Due Time: Why Maternal Age Matters, a September 2011 report by the Canadian Institute for Health Information. Using 2007 data, the report indicates women over 40 have a one-in-eight chance of gestational diabetes, compared to a one-in-12 chance for women 34 to 39, and one-in-24 for women 20 to 34.
And poor blood sugar management can lead to problems for both mom and baby, explains Julie Paterson, a Sunnybrook diabetes nurse educator. Babies can grow too large, for example, causing trauma during delivery, or suffer a low-blood sugar reaction during delivery and require care in the neonatal intensive care unit. These patients are also more prone to breathing problems at delivery and developing jaundice, while larger babies can lead to an increased risk of Caesarean sections.
Sunnybrook gestational diabetes patients receive a blood glucose meter with which to test and record levels. They also attend educational classes about healthy eating habits, and are followed every two weeks in the obstetrics endocrine clinic until they deliver, and then postpartum. "If we can control the blood sugars, we can prevent these things from happening," says Julie.
Older moms are also at an increased risk of developing gestational hypertension, which can lead to low birth weight and early delivery. In Due Time indicates 20- to 34-year-olds have a 3.9 per cent chance of getting gestational hypertension, 35- to 39-year-olds a 4.2 per cent chance, and those 40-plus a 5.6 per cent chance. The risk of pre-eclampsia also increases significantly for those over 35.
While the condition is treatable, the tricky part for some is trading that business trip or important trial for much-needed bed rest. While these patients may not be used to losing control of their careers, Dr. Zaltz says most realize getting off their feet and slowing down is for the best. "It becomes about the baby and not them," says Dr. Zaltz.
Women 35 and over have an increased risk of preterm births, with rates more than 20 per cent higher than for those 20 to 34, according to In Due Time. This demographic is also more likely to have multiples due to their increased use of assistive reproductive technology, and Raising Expectations points out more than 50 per cent of twins and 90 per cent of triplets are born prematurely.
Prematurity comes with a long list of complications, including lung infections and learning disabilities. Sunnybrook's NICU, which opened in September 2010 and is the newest and most modern level III facility in the country, cares for 20 per cent of all infants in Ontario weighing less than three pounds.
Sunnybrook is also the only hospital in Ontario using human donor milk, which has proven to drastically reduce infections and improve patient outcomes, and is among the top three hospitals in Canada for healthy lung outcomes.
And the NICU Follow-Up Clinic tracks the progress of each child at least until the age of six, working to ensure these patients have the support they need within their communities; follow-up care for preemies elsewhere typically ends at the age of two. The clinic is directed by Dr. Paige Church, one of only two pediatricians in North America and the only one in Canada with a combined fellowship in Neonatal-Perinatal Medicine and Developmental Paediatrics.
The good news is that, with the help of Sunnybrook's multidisciplinary team, starting a family can absolutely be a dream come true for these patients. "Despite the increased concerns with advanced maternal age, good preventative care, good health and supportive obstetrical care can lead to the birth of a healthy baby," says Dr. Zaltz.