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By the time most girls reach middle school, they know about the dangers of having children too young. But health education classes rarely cover the flip side: The hazards of getting pregnant too old.

In August, The New York Times published a story headlined “Are You as Fertile as You Look?” For many women, the answer is no. A 41-year-old magazine editor interviewed for the story underwent 15 rounds of in vitro fertilization (IVF), and is now attempting to have a baby with a donor egg. She said she was shocked to find out despite working hard to look younger than her age, she had reached the end of her reproductive life.

The editor’s story is not unusual: Women between the ages of 35 and 39 have about a 50 percent chance of getting pregnant within a year of trying. By the early 40s, the chance of success is down to around 1 in 3.

The unfortunate reality is that as women accrue the wisdom, perspective, and security it takes to be a mother, their chance of achieving a healthy pregnancy declines. The majority of women who are able to get pregnant after age 35 have a healthy baby. But they also have a higher risk than women in their 20s of just about every bad outcome, including birth defects, miscarriage, and pregnancy complications.

The March of Dimes summarizes the risks of pregnancy after age 35, which include:

• Gestational diabetes: double the risk
• Stillbirth: double or triple the risk
• Hypertension and preeclampsia: higher risk
• Placenta previa, a complication where the placenta covers the cervix: double the risk in the late 30s, and three times the risk over 40

That hasn’t stopped women from having children later in life. In 1990, 13 percent of all U.S. births were to teens, compared to 9 percent for women 35 and older. That trend had reversed by 2008, with 14 percent of births to women 35 and older, and only 10 percent to teens. And one out of every five women in the U.S. now has her first child after age 35.

So what is the perfect age to get pregnant? In one online opinion survey conducted in 2010 by ForbesWoman and TheBump.com, the highest number of votes was for 25 to 29. Of the 2,210 women who responded, 42 percent picked that age range.

In a Forbes article about the survey, Heidi Murkoff, a co-author of the What to Expect books, cautioned women not to wait too long.

“Planning pregnancy for the time in your life that’s just right is ideal, but it’s not necessarily realistic,” Murkoff said. “In waiting for that ideal day to dawn, you may find that it never does.”

New York Times hyperlink
http://www.nytimes.com/2011/09/01/fashion/fertility-is-a-matter-of-age-no-matter-how-young-a-woman-looks.html

The March of Dimes hyperlink
http://www.marchofdimes.com/pregnancy/trying_after35.html

Forbes hyperlink
http://www.forbes.com/2010/03/01/family-career-working-mother-forbes-woman-time-best-age-to-have-children_3.html

Photo by Flickr user netdance (CC BY-NC-ND 2.0)

When Michelle was preparing for in vitro fertilization (IVF), her doctor told her that he wanted to transfer three to five embryos. Her response: “Absolutely not.” She told him that she wanted only one baby. They settled on two embryos, and the result was a twin pregnancy. At 32 weeks, she delivered the boys, who weighed only four pounds each. They went straight to the neonatal intensive care unit, where they were fed through a tube in their nose. It was a month before she could bring them home.

Michelle shared her experience for a new CDC video that promotes single embryo transfer.

“What the public doesn’t really understand, and even physicians, I think, don’t appreciate to some degree, is even twin pregnancies do have a much higher chance of all kinds of complications,” Dr. James Goldfarb, the current president of the Society for Assisted Reproductive Technology, said in the video posted on the CDC’s website. “And really, the goal is to have one healthy baby.”

It is still too early to tell whether such messages are making an impact on younger couples considering IVF. But it is clear that many infertile couples in the U.S. are still willing to risk having twins. For many, the reasons are emotional. After trying for so long to have a baby, many couples want children so badly that they would happily take on all the sleepless nights and double expenses that come with twins.

But one of the biggest obstacles for many couples is financial. Only a handful of states require insurance companies to pay for IVF treatment, so in most places, couples have to pay the entire cost themselves. The typical price for IVF is $10,000 per cycle – or more. So if the single embryo transfer doesn’t result in a pregnancy the first month, the couple will have to pay more money (although usually less than the full price) to try with another embryo following month.

Some experts say that public service announcements aren’t enough. In order to reduce the number of multiples and resulting complications, they say it will take a nationwide policy change. In places like Quebec and Sweden that have achieved low rates of multiple pregnancies, the government pays for treatment, so couples do not risk thousands of dollars if they don’t get pregnant the first month. Although treatment carries a high price tag, those countries save money by preventing preterm birth.

A study published this month estimated that preterm delivery resulting from fertility treatment cost the U.S. healthcare system $1 billion per year. According to the CDC (see graph at right), among babies conceived by assisted reproductive technology, 63.3 percent of twins and 95.3 percent of triplets are delivered preterm. The Board of Health Sciences Policy estimates that each one of those preterm infants costs $51,600.

And those are only the financial costs. No economic analysis can quantify the fear and worry of new parents, already survivors of infertility, as they spend months in the hospital with their tiny babies.

See the CDC videos here: http://www.cdc.gov/art/PreparingForART/index.htm

Bromer JG et al. Preterm deliveries that result from multiple pregnancies associated with assisted reproductive technologies in the USA: a cost analysis. Curr Opin Obstet Gynecol. 2011, 23(3):168-73.

According to the most recent statistics, nearly 1 in every 31 pregnant women is expecting twins. That rate is about three times higher than it was in the 1950s, in part because women are having babies at older ages, and women over 35 naturally conceive more multiples. But most of the increase has been caused by fertility drugs and in vitro fertilization (IVF).

Carrying twins or higher-order multiples takes a toll on the mother, putting her at higher risk of nearly every pregnancy complication – preterm birth, hypertensive disorders including preeclampsia and eclampsia, anemia, gestational diabetes, placenta previa, and postpartum hemorrhage. Half of all twins have to be admitted to the neonatal intensive care unit, and an estimated 7 percent have lifelong disabilities due to prematurity. The rates are even higher for triplets; 95 percent are admitted to intensive care.

To prevent those risks, the Society for Reproductive Medicine recently adopted the recommendation that IVF patients under age 35 transfer only one embryo at a time. In elective single embryo transfer, doctors choose the most viable embryo and preserve the others. If the woman does not get pregnant, the remaining embryos are transferred, one at a time, in future months. That recommendation is based on growing evidence that in younger women who are more likely to get pregnant, transferring a single embryo reduces the risk of multiples without reducing pregnancy rates.

New evidence from Europe

A study published this month by researchers in Barcelona confirmed that single embryo transfer works. The researchers followed 628 couples who underwent IVF between 2002 and 2006. In total, 66 percent of couples who chose a single embryo each month got pregnant, compared to 70 percent of couples who chose to transfer two. Only 7 percent of couples who chose a single embryo had twins, compared to 27 percent of the couples who transferred two embryos at once.

In Quebec, it’s now the law

In 2010, Quebec became the first Canadian province to pay for IVF treatment for couples – up to three tries for women under the age of 42. But as part of the plan, the government passed a law saying that physicians should only transfer one embryo at a time. Doctors could choose to transfer more than one embryo in patients with a poor prognosis, but only if they provided justification. In the first three months that the law was enacted, the multiple pregnancy rate for IVF patients in Quebec dropped from 26 percent to less than 4 percent.

In a few countries, including Sweden and Australia, single embryo transfer is already the norm. But in the U.S., many women still choose two embryos. I’ll discuss the reasons for that – and some ways that experts hope to change couples’ decisions – in my next post.

Rodriguez DB et al. Elective single embryo transfer and cumulative pregnancy rate: five-year experience in a Southern European country. Gynecological Endocrinology, 2011. [epub ahead of print].

Bissonnette F et al. Working to eliminate multiple pregnancies: a success story in Quebec. Reprod Biomed Online. 2011, 23(4): 500-4.

Photo by Flickr user cafenut (CC BY-NC-SA 2.0)

The number of women diagnosed with gestational diabetes could soon rise, and possibly even double or triple, if doctors adopt the stricter standards advocated by the American Diabetes Association.

The proposed standards are based on findings from the Hyperglycemia and Adverse Pregnancy Outcomes study, which showed that as a mother’s blood glucose levels go up, so do her risks of a Caesarean section and a host of other complications, including pre-eclampsia, preterm delivery, and giving birth to an infant who weighs more than 9 pounds or requires intensive care. Women with borderline blood glucose levels are at higher risk than those with low levels, even if they fell below the threshold of gestational diabetes.

Some experts have also pointed out that while diabetes dramatically increases the mother’s risk of having a baby born too large, the majority of babies weighing more than 9 pounds are actually born to mothers who do not have gestational diabetes. Many of the outcomes typically associated with gestational diabetes are also the result of maternal obesity and/or excessive weight gain during pregnancy.

Although experts are still debating the new guidelines, they agree on the importance of physical activity and a healthy diet. The best approach for all pregnant women is to cut back on the simple carbohydrates found in sugar, white bread and white rice, and get more whole grains, vegetables, beans, nuts, and lean proteins (think the Atkins, Mediterranean, or South Beach diets). These foods have a low glycemic index, which means they do not cause spikes in blood sugar.

Eating smaller, more frequent meals also helps to control blood glucose levels. Women should try to keep their weight gain within the recommended range of 25 to 35 pounds (less for women who begin pregnancy overweight).

For more tips on nutrition in pregnancy, see the USDA’s list of resources:
http://www.nal.usda.gov/fnic/pubs/bibs/topics/pregnancy/pregcon.pdf

Although more research is needed, it is possible that better control of blood glucose levels during pregnancy can improve the baby’s lifelong health. Some studies suggest that being exposed to too much glucose in the womb may increase the baby’s risk of obesity, diabetes and cardiovascular disease later in life.

International Association of Diabetes and Pregnancy Study Groups Consensus Panel.
International Association of Diabetes and Pregnancy Study Groups Recommendations on the Diagnosis and Classification of Hyperglycemia in Pregnancy. Diabetes Care. 2010, 33(3): 676-682.

Cundy T. Proposed new diagnostic criteria for gestational diabetes – a pause for thought? Diabet Med. 2011, Aug 9. (Epub ahead of print].

Odent, M. Gestational diabetes and health promotion. The Lancet. 2009, 374(9691): 684.

Photo by Flickr user Martin Cathrae (CC BY-SA 2.0)

Between weeks 24 and 28, pregnant women are screened for gestational diabetes, a type of diabetes that develops for the first time in pregnancy. Those who screen positive typically return for a three-hour diagnostic test, which usually requires the pregnant woman finish a sugary drink and then undergo a series of blood draws over three hours. Women who have abnormal glucose readings are diagnosed with gestational diabetes. About 3 to 5 percent of pregnant women, or 135,000 per year in the U.S., are diagnosed.

A generation ago, doctors typically reassured women that the condition was temporary. But it is now clear that while blood sugar levels return to normal after the birth, gestational diabetes puts women at high risk of developing type 2 diabetes later in life.

A 2009 study published in The Lancet that pooled the results of 20 individual studies found that the lifetime risk of type 2 diabetes was about seven times higher in women who had gestational diabetes than those who did not. The U.S. Centers for Disease Control and Prevention estimates that anywhere between 15 and 50 percent of women who had gestational diabetes in pregnancy will develop type 2 diabetes.

Gestational diabetes can also cause more immediate problems, including babies that weigh more than 9 pounds at delivery. Big babies are more likely to dislocate a shoulder during birth and put women at risk of a Caesarean section.

Scientists do not know exactly how gestational diabetes leads to type 2 diabetes. Genetic studies provide some evidence that they have a common cause: Women who get gestational diabetes often carry the genes that predispose people to type 2 diabetes.

The risk factors for gestational diabetes are similar to those for type 2 diabetes and include:

• A previous pregnancy with gestational diabetes or a baby weighing more than 9 pounds
• Being overweight or obese
• Being older than 25
• Having a family history of diabetes
• Being African-American, Hispanic, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander.

However, 40 to 60 percent of women who develop gestational diabetes have no known risk factors, which is why doctors in the U.S. typically require all pregnant women to be screened.

U.S. Centers for Disease Control and Prevention. Gestational Diabetes. http://www.cdc.gov/diabetes/pubs/pdf/gestationalDiabetes.pdf
Accessed November 21, 2011.

Bellamy, L et al. Type 2 diabetes mellitus after gestational diabetes: a systematic review and meta-analysis. The Lancet. 2009, 373(9677): 1773-9.

Photo by Flickr user Lara604 (CC BY 2.0)

At some point before they deliver, nearly 20 percent of all pregnant women – 1 million per year in the U.S. – are put on bed rest. The prescription varies, depending on the doctor and the seriousness of the complication. Some women are told to stay in bed as much as possible, others are told not to walk anywhere except the restroom, and some women will be hospitalized. For some women, bed rest only lasts for a day or two; others will be told to stay in bed for months, until they give birth.

The practice is nearly universal: 95 percent of all OBs say that they prescribe bed rest. They order it for a variety of reasons: to prevent miscarriage, postpone delivery, and manage complications including bleeding, hypertension and pre-eclampsia. Some fertility specialists recommend bed rest as a way to improve the chance that an embryo will implant after in vitro fertilization.

But at least three teams of scientists in the last two years have called the practice into question, saying that there is not enough evidence that bed rest does any of those things.

Catherine Bigelow and Dr. Joanne Stone traced the history of bed rest for an article published this year in the Mount Sinai Journal of Medicine. The ancient Greek physician Hippocrates was the first to prescribe bed rest to his patients, and by 1900, it was used for a variety of conditions, including pregnancy. Some doctors prescribed pregnant women sedatives to make sure that they weren’t tempted to get out of bed. But bed rest began to fall out of favor in the 1950s, when NASA scientists used bed rest to simulate weightlessness and found it caused muscle atrophy and bone loss. Doctors stopped prescribing it for most conditions after studies showed that it did more harm than good for patients with tuberculosis and heart attacks.

Despite that shift in thinking, bed rest remains one treatment of choice for high-risk pregnancies. Bigelow and Stone say that doctors need to consider all of the implications of putting a woman on bed rest. Women who have limited maternity leave may find that they have to use up much of that time before the baby arrives, and those who don’t have paid time off from work can take a large financial hit. Not surprisingly, according to Bigelow and Stone, studies have found that women on bed rest are more likely to report “anxiety, depression, and hostility.”

There are also physical effects of lying in bed all day. At a time when women’s calcium stores are depleted to help build the fetal skeleton, bed rest can also accelerate bone loss. And some studies have shown a small increase in the risk of blood clots.

So, what evidence is there to support bed rest? According to three teams of researchers who reviewed the evidence to date, there isn’t much. Bigelow and Stone concluded that there is no consistent evidence of a benefit for any complications of pregnancy, including for pre-eclampsia and hypertension. After analyzing seven large studies for the Cochrane Review, Crowther and Han found no benefit of routine hospitalization for bed rest for improving birth outcomes in multiple pregnancies. And Maloni, who authored a review published in 2010, concluded that bed rest does not have any demonstrated benefits for women at risk of preterm birth.

In one study published in 2008, a team of doctors at the University of Montreal led by Dr. Haim Abenhaim did find a reduction in cases of pre-eclampsia among hospitalized women on bed rest. The doctors looked at the medical records of 677 women hospitalized for complications other than hypertensive disorders at one teaching hospital in Montreal between 1991 and 2001. They found dramatic reductions in pre-eclampsia and fetal growth restriction among the hospitalized women, compared to all women who delivered during that decade. Despite that finding, Abenhaim and colleagues said it is remains to be determined which women should be given bed rest, at what point in pregnancy, and how restrictive it should be.

Abenhaim, HA. Evaluating the role of bedrest on the prevention of hypertensive diseases of pregnancy and growth restriction. Hypertension in Pregnancy. 2008, (27):197-205.

Bigelow C and Stone, J. Bed Rest in Pregnancy. Mount Sinai Journal of Medicine. 2011, (78):291-302.

Crowther CA and Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev. 2010, 7(7): CD000110.

Maloni,JA. Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth. Biol Res Nurs. 2010, 12(2):106-24.

After week 20 of pregnancy, 4 to 8 percent of women will develop pre-eclampsia, a potentially dangerous condition that can result in organ damage and death in extreme cases. Pre-eclampsia is diagnosed when a pregnant woman has two separate blood pressure readings taken six hours apart of 140/90 or higher and protein in her urine.

In rare cases, the disease can progress to eclampsia, which can cause seizures and is potentially fatal. Researchers don’t know what causes pre-eclampsia, or why it progresses in some women. There is no way to treat severe pre-eclampsia except to deliver the baby. In most cases, doctors are able to closely monitor women with pre-eclampsia until the 36th week of pregnancy, when the prognosis for the baby is good. But if the disease becomes severe earlier in pregnancy, doctors are forced to weigh the mother’s health against her baby’s potential for survival.

Because pre-eclampsia causes 15 to 20 percent of maternal deaths, early detection is critical. Women who are at high risk should closely monitor their blood pressure in the second and third trimesters.

The number one risk factor for pre-eclampsia is developing high blood pressure or pre-eclampsia in a previous pregnancy, especially if it happened early. Other risk factors include:

• First pregnancy
• Multiple pregnancy
• Age over 40,and possibly 35
• Obesity (BMI 30 or higher)
• African-American race
• Family history of pre-eclampsia
• Type I or gestational diabetes
• Chronic hypertension, renal disease, thrombophilias

What You Can Do

In a recent review of research to date, experts recommended that pregnant women consult with a specialist before 20 weeks if they have any of the following risk factors: Pre-eclampsia in a previous pregnancy, multiple pregnancy, or have pre-existing hypertension, renal disease, diabetes, or protein in the urine.

Pre-eclampsia often has no symptoms, which makes it even more important for pregnant women to keep all of their prenatal appointments. A high blood pressure reading may be the first sign that something is wrong.

Other possible symptoms to look for are swelling, sudden weight gain and a sharp pain under the rib cage, on the right side. Swelling in the feet and ankles is common during pregnancy, but sudden swelling in the hands and feet can be a symptom of pre-eclampsia. Weight gain is also inevitable in pregnancy, but a sudden spike of more than 2 pounds a week can be a warning sign.

Women should also monitor their blood pressure prior to pregnancy, so that they can tell their doctor if a slightly high blood pressure reading is typical or a sign of a potential problem.

Women who are at high risk should ask their doctors whether they should take calcium supplements or low doses of aspirin. The most current research suggests that in women who have calcium deficiencies, supplements may help to prevent pre-eclampsia. But the research isn’t conclusive for women who already get enough from their diet.

Low doses of aspirin also may help, but researchers don’t recommend that women take it before the 12th week of pregnancy. And the benefits are likely to be small – aspirin may only prevent an estimated 1 out of 69 cases of pre-eclampsia in women who take it.

Briceño-Perez C et al. Hypertension in Pregnancy. 2009; 28:138-155.

Trogstad L et al. Best Practice & Research Clinical Obstetrics and Gynaecology. 2011, 25: 329-342.

Turner, JA. Diagnosis and management of pre-eclampsia: an update. Int J Women’s Health. 2010; 30(2): 327-37.

Wagner, LK. Diagnosis and Management of Preeclampsia. Am Fam Physician, 2004; 70(12): 2317-2324.

NIH. Your Guide to Lowering High Blood Pressure. http://www.nhlbi.nih.gov/hbp/issues/preg/preclamp.htm

Photo by Flickr user Warren Raquel (CC BY-NC-SA 2.0)

We’ve come a long way since the era of our great-grandmothers, when death in childbirth was a very real risk. But complications of pregnancy are still common: By the time we reach our 30s, most of us know at least one woman who has faced a problem like gestational diabetes, late-pregnancy bleeding, or pregnancy-induced hypertension. These complications are often serious: for every 100 births, there are 12.8 pregnancy-related hospitalizations.

One in every 4,950 pregnant women in the U.S. die of complications from pregnancy or childbirth, more than double the proportion who die in western Europe. The rates of some common pregnancy complications – particularly blood pressure disorders and gestational diabetes – are now on the rise. In part, that is because women are beginning pregnancy older and heavier than in generations past. And fertility treatments have led to more women carrying twins and higher-order multiples, which come with higher risks.

Despite dramatic improvements in medical care and treatment, common complications of pregnancy are still poorly understood. Scientists aren’t sure what causes pre-eclampsia, a disorder that affects 5 to 8 percent of pregnant women and can force doctors to deliver the baby before term. Studies are divided on how much exercise is too much, and whether certain vitamins may help pregnant women control their blood pressure. One recent review concluded that bed rest, which doctors prescribe to nearly 20 percent of pregnant women, may have little or no benefit at all.

In this blog, I’ll share the latest research on these complications and what women can do to avoid them.

Loudon I. Maternal mortality in the past and its relevance to developing countries today. American Journal of Clinical Nutrition, 72 (1). July 2000: 241S-246s.

CDC. 2002 PRAMS Surveillance Report: Multistate Exhibits Hospitalizations for Pregnancy-Related Complications. http://www.cdc.gov/prams/2002pramssurvreport/multistateexhibits/multistates14.htm

Lozano, R et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic review. The Lancet, 378(9797): 24-30 Sept, 1139-1165.

Bigelow C and Stone J. Bed Rest in Pregnancy. Mount Sinai Journal of Medicine, 78: 291-302.