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By Dr. Kameelah Phillips

Being pregnant can be one of the most exciting and anxiety-provoking times of a person’s life. Maybe you have traveled around the world, earned degrees, and now you are here. And by “here” I mean over 35 and pregnant. Your first OB visit can be quite sobering when your body and mind feel not a day over 27, yet you see your chart labeled “geriatric,” “elderly,” or “advanced maternal age.” What is going on? Welcome to the Advanced Maternal Age (AMA) pregnancy!  

My experience with AMA

Several years ago, I was in your shoes. I had my children at 36, 37 and 40. Even before having children, I was completely turned off by these antiquated terms. The experience of being an Advanced Maternal Age (AMA) patient myself while being an Obstetrician allows me to relate to the concerns and anxieties of women like you. So, let’s have a frank discussion about your concerns regarding the changes in prenatal care after 35. Let’s learn why these recommendations are important. Please remember, this discussion may not apply to you as an individual. This does not substitute for medical advice from your personal OB/GYN.

The terminology

Let’s start with the terminology. In my dual experience as a doctor and patient, I recognize the sting that the terms “Advanced Maternal Age (AMA),” “elderly,” and “geriatric” can have on obstetric patients. I reframe these terms for patients. Feel empowered by the ability of your body to carry a pregnancy at any age! These historic (think 1950s)  terms are a means of communication between medical staff, insurance companies, and researchers. In short, they help us understand patient risk, explain evaluations (that may otherwise be denied) and develop best practice standards for women in this age group.

In other words, I encourage patients to remember that these terms are helpful for a medical conversation. They are not intended as personal slights towards you or your pregnancy. To sum up, embrace all this experience has to offer and leave the terminology for the research. There are many advantages to having children later in life. In short, my hope for you is that the terminology for your pregnancy does not minimize your experience.

The realities that come with age

As a “midlife mother” (my own term–not medical by any means), we have to deal with some realities that come with age. In general, pregnancy-related research has consistently demonstrated an increase in obesity, high blood pressure, and diabetes as women age. As doctors and researchers, our job is to minimize the impact of these conditions in pregnancy at every age.

This data and our collective experience influence decisions regarding fetal monitoring and interventions such as labor induction. For example, some institutions may increase fetal monitoring around 36-38 weeks. This approach is due to ample research demonstrating the increased risk of gestational diabetes, high blood pressure, and stillbirth as pregnancies progress. Increased surveillance helps us avoid or minimize any negative outcomes for women and babies. (Source 1-3) Therefore, while these conditions may not be on your personal radar, they are on our radar as risks that should not be overlooked or ignored. 

Concerns regarding ultrasound use

Similarly, some patients also have concerns regarding the increase in ultrasound use. Ultrasound is one of the most helpful tools for the Obstetrician. Ultrasounds provide information via sound waves–not radiation like a CAT scan. In the Obstetric setting, ultrasounds are not dangerous to the mother or baby. They often provide valuable information regarding the wellbeing of your baby. For example, this can include early changes in blood flow to and from the placenta and changes in amniotic fluid. These can reflect early signs of placental dysfunction. Ultrasounds help us evaluate the baby in a way that is not possible at a routine visit.

I encourage women to have these ultrasounds with the understanding that sound waves do not cause fetal harm. If significant findings are present, then interventions may be warranted for the health of the mother and baby. Most importantly, it is our job to prevent poor outcomes, and information from ultrasounds often helps us in this process. (Source 4) 

Initiate conversations with your provider early

I encourage you to initiate early conversations regarding your health and age related concerns. It will help you manage your anxiety. You’ll better understand the management strategies specific to you, your medical history, ethnicity, and number of pregnancies. There is no cookie cutter approach to any pregnancy! There are, however, some strong recommendations for management of “midlife mothers.”

For example, at the first visit, I frequently let mothers know that a 40-41 week pregnancy is not recommended for her. I start this conversation early, and I encourage open and ongoing dialogue. When you understand why your doctor is making certain recommendations, you can feel comfortable with proceeding. You and your provider should work to cultivate trust over the 39 weeks of pregnancy. Moreover, engaging in this conversation also helps you manage your expectations for subsequent visits or ultrasounds. 

Medicine as art

What seems like a variation in practices among doctors around monitoring and delivery of AMA pregnancies frustrates many patients. This represents the intersection of medicine as an art and medicine as a science. It also represents how recommendations for one patient do not always apply to the next. Conversations regarding monitoring and delivery are challenging for both patient and doctor.

From a patient perspective, I hear expressions of fear, anxiety, and hesitancy about bringing the pregnancy to an end. We often have a belief that staying pregnant “as long as possible” is inherently the right thing to do. From the Obstetrical perspective, however, I consider the nuances and limitations of fetal testing, individual risk, research studies, and the archive of my medical expertise in this area. This helps me fine tune my decision-making process with patients. All of this contributes to decision-making that is not only individualized, but within safe guidelines for the mother and baby.  

Find a healthcare provider you can trust

As with any major life change and challenge, surround yourself with people that you trust and communicate well with. Certainly, this should include your healthcare provider! If you have not had a good working relationship with your GYN, then it may be unlikely that this will change in pregnancy.

Read our series if you need help choosing your birth team.

Firstly, Find a provider that you feel you can trust and is open to discussing issues. This will be the cornerstone of your obstetrical journey, and it is important that it be established early on. Secondly, use your initial visits to discuss any early identifiable concerns that may indicate an induction. If this is the case, you can use your time to learn more about the condition and inductions. Gather information from reliable sources like the American College of Obstetricians and Gynecologist (ACOG). Don’t rely on chat rooms, a Google Search, You-Tube video, or other non-vetted sources. Finally, talk to a range of mamas about their labor experiences. Above all, I believe you will find a consistent goal of a healthy mother and baby. 

Tips for those TTC for an AMA pregnancy

You may have been taught to believe that pregnancy over 35 is “high risk” or “dangerous.” If you are thinking about conceiving, here are a a few practical steps as you embark on this journey. First, I recommend you prepare for pregnancy by selecting a healthcare provider that you trust. As discussed previously, being able to have open conversations fosters trust. Secondly, consider a pre-conception counseling visit with your provider.  During this visit, you and your partner (if applicable) can ask questions regarding what to expect during pregnancy as it relates to testing, monitoring, and delivery. As a result, this will help you manage your expectations when you do become pregnant.  

As previously mentioned, depending on your medical risk factors, your provider may recommend induction at or around 39 weeks. The goal is to deliver a full-term infant and minimize the risks of AMA pregnancies. With that consideration, we hope to individualize your care. For example, ultrasounds and weekly visits help reassure the health of the pregnancy and can contribute to discussions regarding induction. Feel free to bring up this conversation at your preconception and initial OB visits. (SOURCE MISSING – 5) Thirdly, use the information gathered at your preconception visit to modify issues that you can control. If you have hypertension, diabetes, or any other pre-existing condition, work to manage it with diet, exercise, and medication.

Choose to focus on the joy of pregnancy

In conclusion, you can choose to focus on the joy of pregnancy and your new family member or you can choose to worry about your age! I encourage women to do the former. Let me–as your healthcare provider–deal with the potential issues of the pregnancy. You are growing a human–this is amazing!  This is a time to dwell in a spirit of happiness and positive energy, so enjoy, mama!

Sources:

  1. The risk of stillbirth and infant death by each additional week of expectant management stratified by maternal age. Page JM, Snowden JM, Cheng YW, Doss AE, Rosenstein MG, Caughey AB. Am J Obstet Gynecol. 2013;209(4):375.e1. Epub 2013 May 23.
  2. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Reddy UM, Ko CW, Willinger M. Am J Obstet Gynecol. 2006;195(3):764.
  3. Maternal age and the risk of stillbirth throughout pregnancy in the United States. Reddy UM, Ko CW, Willinger M. Am J Obstet Gynecol. 2006;195(3):764.
  4. ACOG Committee Opinion Number 723.
  5. MISSING

About Dr. Kameelah

 dr-kameelah-advanced-maternal-ageDr. Kameelah Phillips is a board certified Obstetrician and Gynecologist, wife, mother, and lifelong women’s health advocate. Since high school, she has been involved in local, national, and international organizations aimed at advancing women’s health care issues through advocacy and direct patient care.

Dr. Phillips graduated from Stanford University with a degree in Human Biology with an emphasis in Women’s Health and Human Sexuality. After graduation, she worked at the San Francisco Department of Public Health in the AIDS office as a Research Assistant on HIV vaccine studies. She relocated to Los Angeles to attend the University of Southern California Keck School of Medicine.

During medical school, she received numerous community service awards. She was privileged to travel to Ghana, Cuba, and Tanzania on health missions during this time. Upon completion of medical school, she attended a competitive OB/GYN residency at the New York University School of Medicine. She also served on an emergency medical mission in Port-au-Prince, Haiti to provide women’s health care during the 2010 earthquake. Dr. Phillips is an educator, mentor, and expert in women’s health issues.   She loves to help women and girls feel comfortable with their bodies, so that can be aware of changes or new developments.  Her interests include prenatal care, lactation, sexual and menopause medicine. Dr. Phillips is a member of the International Board of Lactation Consultants and speaks Spanish. She enjoys teaching residents and medical students.

Her guilty pleasures include reality TV. As a Real World Alumnae, she has used this platform to travel nationwide to discuss domestic violence, smoking cessation, and other health-related issues. She loves a good bargain, flowers, and deep-tissue massages. You can follow her on Instagram @drkameelahsays or @callawomenshealth.