The Doctor Weighs In

Marilynn Marchione, a medical writer for AP, reports that “high-risk pregnancies are on the rise in the United States and may be more common now than at any other time since modern obstetric care became available.”

There are lots of reasons why the high risk pregnancy rate is increasing. Many women are deferring pregnancy until their late thirties and early forties, and beyond. Obstetricians counsel potential parents that women past about 35 may potentially have more difficulty getting pregnant and also that the fetuses are at increased risk of genetic problems, such as Downs Syndrome.

Despite that, modern life dictates that more and more women and men are deferring pregnancy into their 30s and 40s. They are older, many are wiser, and most are financially more stable than my generation of 20 something parents. These are attributes that could more than offset the somewhat increased medical risks these pregnancies entail.

Pregnancy after menopause

In addition to the “late youngers,” we are also seeing “early and late olders” using in vitro techniques in order to become pregnant long after normal ovarian function has ceased. These women of “a certain age” are now choosing to become pregnant despite the risks to themselves and their offspring, but obstetricians are saying that many of these risks are manageable. We have amniocentesis, ultrasounds, fetal monitoring, neonatal intensive care units and all manner of medical care to diagnose and manage maternal, fetal, and post-partum complications.

Dr. Mary D'Alton, the Columbia University Medical Center obstetrics chief who recently delivered twins to a 59-year-old woman, says that she has replaced the term "high-risk" with a 1-to-10 scale. This is a very different environment from the one which my generation faced. I was 24 years old when my son was born. 24!

By the time I went to medical school at the ripe old age of 28, my son, Jason was four.   (Aside:  he is now a radiologist, married to Amy,  they are mother and father of one of our granddaughters, the little Kate Rose.)   My contemporaries in med school were deferring pregnancy until after their graduation or residencies, some to ages 26-35, or even older.

By the time I as in my early 40s, Jason was in college and I experienced, for the first time, how much selfishness is possible in an empty nest. Now, older parents face the prospect of being elderly (can I use that word?) by the time their kids graduate from high school. 

There was a recent news report  about a women who lied about her age and conceived a child via IVF at the age of 67. That means she will be 85 when her kid goes to college.  85!  Not one of my close relatives have made it to 85 ( I do not come from long-living stock).  If any of them would have given birth at age 67, then, for sure, their offspring would have been orphans in their teens.

I have men friends who had their kids in their 50s and now feel they can’t retire because they are facing college tuitions coming due in their 70s. Hmmmm. It was hard to be a parent of a young child when I was in medical training, but it must be even harder to be the parent of a teen-ager when you are 70 or 80 or even 90!

Chronic illness is no longer a reason not to have a baby

Chronic illnesses, such as Type 2 diabetes and high blood pressure have increased in younger people because of the epidemic of obesity in this country. These conditions have been associated with increased pregnancy complications in the past. But better ability to monitor and treat these conditions as well as more sophisticated obstetric approaches have allowed many women with these chronic conditions to deliver healthy children safely.

Only a few years ago, women who have had cancer, HIV, or an organ transplant would have found it inconceivable (so to speak) to get pregnant. But, according to the AP report, tens of thousands of organ transplant recipients, breast cancer survivors, women with heart defects, and even women with the AIDS virus have decided to risk childbearing in the last several years.

Marchione's article lists of number reasons why high risk pregnancies are increasing:

•  "Older moms. In 2005, there were more than 104,000 births in the United States to women ages 40 through 44, and over 6,500 to women 45 and older. Advanced age raises the risk of birth defects.
• Chronic health problems. Obesity among women ages 18 to 44 rose from under 9 percent in 1990 to almost 22 percent in 2005.  Hospital admissions for diabetes or related conditions among pregnant women and new mothers rose from 175,655 in 1993 to 269,861 in 2004, says the March of Dimes. Admissions for high blood pressure rose from 260,222 to 403,271.
• Multiple births, often the result of infertility treatment. In 2004, they made up more than 3 percent of all live births, up from about 2 percent in 1980. Such babies are more likely to be born prematurely and to have health problems.
• More cancer survivors. Hundreds of thousands are in their prime childbearing years. "Pregnancy raises enormous concerns for women with a history of breast cancer because we know that many breast cancers are hormonally driven," and high estrogen levels during pregnancy might raise the risk of relapse, said Julia Rowland, director of the National Cancer Institute's Office of Cancer Survivorship. "They may also be concerned that they may not be here for a child."
• Better medical care. Women with congenital heart defects used to die young. Those who lived were urged not to get pregnant. Now many such defects can be fixed, and children of women with heart defects are having their own children.
•  More drugs. Nearly two-thirds of women who gave birth from 1996-2000 took a medication during pregnancy, a large federally funded study found. Of those, nearly 40 percent took a drug whose safety in pregnancy is not established, and nearly 5 percent took a drug potentially risky to the fetus. More pregnant women have taken new medicines for cancer, depression and other problems. More than 30 registries now track outcomes of pregnant women on various drugs.
• Growing prevalence of HIV. Each year, about 6,000 to 7,000 HIV-infected American women give birth. Such pregnancies have been controversial because of the risk of spreading the virus to their babies. But modern AIDS drugs are so effective at protecting babies from the virus' spread that more doctors are accepting these women's choice to have children."

According to the AP article, Temple University's Dr. Vincent Armenti, who runs a registry that tracks births to transplant patients, is quoted as saying, high risk women who face high risk pregnancies “define a whole new era of pregnancy for us…we have to change our mindset about the perfect pregnancy…women should be given advice based on solid research instead of an emotional feeling that some people just shouldn't have a baby."

It is indeed a brave new world peopled by brave new people. Doors that were closed in the past are now open, bringing new challenges, new opportunities, and…new babies.

Pat Salber, MD, MBA