Pregnancy after 40: Recommendations for Counseling, Evaluation, and Management from Preconception to Delivery

Importance Pregnant patients over age 40 often have unique risk factors and potential complications before and during pregnancy that play a role in their counseling and management. Objective To provide practitioners an overview on how to approach preconception evaluation and counseling, prenatal care, and management of associated comorbidities, as well as potential complications, in pregnant patients over age 40. Evidence Acquisition Literature review was performed using OVID and PubMed, with further relevant information queried from guidelines of professional organizations. Results Pregnant patients over age 40 should receive preconception evaluations by their obstetrician-gynecologist and other appropriate specialty care providers as they pertain to preexisting medical comorbidities. In the preconception period, attention should be given to managing and optimizing preexisting medical conditions and associated pharmacotherapeutics. Referral to specialists in assisted reproductive technologies or maternal-fetal medicine should be considered if indicated for appropriate evaluation and counseling. During pregnancy, accurate dating and counseling on aneuploidy screening, with consideration for early diabetes screening, should be performed in the first trimester. A detailed anatomy scan and fetal echocardiogram should be completed by 22 weeks' gestation, along with routine and high-risk (if indicated) prenatal care. Close attention should be given to the development of pregnancy-related complications associated with advancing age. Third-trimester fetal surveillance can be considered. Given that no contraindications exist, these patients should be encouraged to pursue a vaginal delivery with consideration for induction at 39 to 40 weeks' gestation. Conclusion Pregnancy rates are increasing in persons over age 40. As a result, preconception evaluation and counseling tailored to that demographic are essential. In addition to standard prenatal care, they should have early screening and diligent monitoring for pregnancy-related comorbidities associated with advancing age. Relevance With the increased pregnancy-associated comorbidities in patients over age 40, providers should be familiar with how to evaluate, counsel, and manage them during the preconception and pregnancy periods. Target Audience All obstetrical care providers Learning Objectives After participating in this activity, the provider should be better able to explain the benefits of preconception counseling and workup for patients over age 40 desiring pregnancy; identify the impact of chronic medical conditions on pregnancy; and describe antenatal management by trimester for this patient population.