ADVANCED MATERNAL AGE AND PREGNANCY RISKS

There is currently an increasing trend towards delay childbearing across the world. Among the reasons are delay due to longer schooling, late marriage, shift in life priority, financial security, availability of contraception and women exercising their choices.  The consequence of this shift has led to more elderly pregnant mothers.

The commonly accepted definition of advanced maternal age (elderly) is 35 years or more. Studies have shown that pregnancy in this group of women is associated with a higher complication risk to both the mother and baby. Women should be supported in their decisions of whether to have children or not and when to plan childbearing. They should also be aware that the fertility and pregnancy outcomes change with age. For these reasons, women are encouraged to consider having families during the period of optimum fertility.

Pregnancy risks

Maternal age has been shown to affect pregnancy from conception to delivery. Biologically, the best period for pregnancy is between 20–35 years of age. The spontaneous conception rate is 75% in women aged 30 compared to 66% in those aged 35 years old (Leridon 2004). The pregnancy rate in elderly women is lower due to poorer egg quality associated with aging.  There is also a higher risk of spontaneous miscarriage. The reported miscarriage rate at 22 years old is 8.2%, but increases to 20% among women at 35 years of age.

Elderly mother has an increased risk of fetal chromosomal abnormalities and congenital anomalies. The risk of Down syndrome, the commonest cause of mental retardation is significantly increased from 1 in 1000 when the pregnant woman is 25 years of age compared to 1 in 250 at 35 years.

There is also a higher association of preterm birth, small for gestational age (small baby and intrauterine growth restriction, IUGR) among elderly mothers. The preterm delivery may be unexplained or iatrogenic, due to intervention following maternal complications (see below). Elderly mother may be associated with poorer placental perfusion or transplacental flux of nutrients. This led to an increased likelihood of a small for gestational age baby.  All these complications are associated with a higher neonatal intensive care unit admission and higher morbidity.

 

Increase perinatal morbidity and mortality

The risk of stillbirth (fetal demise after 28weeks gestation) is significantly higher in older women, partly due to the risks of aneuploidy (chromosomal anomalies) and fatal congenital anomalies.  The increased incidence of small for gestational age babies in the older women further contributes to the increased stillbirth rate.

 

Maternal complications

Older women are more likely to have pre-existing medical disorders such as diabetes mellitus or hypertension, which further complicate the pregnancy. There is an increased incidence of antepartum haemorrhage, malpresentation, pre-eclampsia and gestational diabetes mellitus.  All these complications lead to a higher operative vaginal delivery and Caesarean section.

 

Conclusions

Pregnant women aged ≥35 years are at increased risk of complications in pregnancy compared with younger women. Although women should be supported in their life choices, they should be aware of the possible problems that older mothers may encounter. Adherent to frequent antenatal visits, under an experienced obstetrician and increased fetal surveillance are some measures that may help to ensure a better outcome.

 

References

  1. Huang L et al., CMAJ 2008.
  2. Leridon H. Human Reproduction 2004
  3. RCOG statement on later maternity age 2009

 

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MRI GUIDED FOCUSED ULTRASOUND (MRIGFUS)- A NOVEL APPROACH TO THE TREATMENT OF UTERINE FIBROID?

Uterine fibroid is one of the commonest benign tumor amongst women.  It is present in 30%  of premenopausal women and is the main indication for hysterectomy.  Currently, there is no effective medical treatment available.  The uterine artery ablation has been offered as alternatives to surgical treatment (hysterectomy) but its clinical application is limited.

The MRI guided focused ultrasound is a minimally invasive fibroid treatment that uses a tightly focused ultrasound waves to deliver heat that instantaneously destroys fibroid tissue.  It is performed as an outpatient procedure with sedation.  The fibroid location is identified using T2-weighted MR imaging followed by a pretreatment planning and application of multiple therapeutic sonications to a temperature of at least 65 degree Celsius.  The heat generated basically ablates the fibroid tissue. The whole procedure takes about two to three hours.  The recovery time of about one to three days appears promising as a viable alternative to the current surgical option.

There are many reports of the experience with this treatment modality.  These reports were not from a high quality study design and occasionally sponsored by industry that are prone to bias and confounding.

There is only one randomized, placebo-controlled trial (PROMISe) to date, that assess the effectiveness of MRIgFUS therapy.  This is a high quality study and has a post treatment follow-up period of 2 years duration.  The result shows there is no diffence between MRIgFUS and placebo group, in terms of symptom improvement and quality of life at 4 to 12 weeks post procedure.  However, about a third (30%) of all women who had MRIgFUS therapy opted for hysterectomy by 2 years post treatment.

In summary, the MRIgFUS treatment for uterine seems promising and avoids the need for surgery.  Currently, the available results suggest its role as a temporary alternative treatment prior to the decision for hysterectomy, at best.

Reference

PROMISe trial (Pilot Randomized trial of MRIgFUS for symptomatic fibroid) trial. Fert Steril 2016

Alternative therapies in management of leiomyomas. Fert Steril 2014

Clinical improvement and shrinkage of uterine fibroids after thermal ablation by magnetic resonance-guided focused ultrasound surgery. Ultrasound Obstet Gynecol 2007.

Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids.  Fert Steril 2006

 

 

 

THE LATEST SCARE – ZIKA VIRUS AND PREGNANCY

For the last two months, the world is shocked by news of microcephalic babies born after suspected Zika virus infected mothers in South America. These babies have smaller than normal head circumference, with high probability of brain damage, blindness or even deafness. It affects more than 2000 pregnant mothers in South America and the government has advised women to postpone pregnancy for six to eight months in order to avoid potential infection.

Zika virus, is a member of the family Flaviviridae, together with dengue and chikungunya viruses. The main transmission is via mosquito bites, mainly the Aedes Aegypti and A. Albopictus. Majority of patient infected with Zika virus are asymptomatic while others presented with mild rash, fever, muscle pain and conjunctivitis. All these symptoms last for about one week. Only a few cases need hospitalization while Gullain- Barrre syndrome has been associated with this infection.

Testing of Zika virus infection in symptomatic pregnant mother can done using immunoglobulin M and neutralizing antibody. When congenital infection is suspected, an amniocentesis can be used to look for Zika virus RT-PCR.

Currently, there is no specific antiviral treatment available for Zika virus disease. The current treatment is generally supportive, including hydration, analgesia and anti-pyrexia.

 Recommendation for pregnant mothers

The CDC recommends that all pregnant mothers should consider avoiding areas where Zika virus transmission is ongoing. For those who have to travel to these endemic areas, a strict adherence to prevention from mosquito bite must be followed. This includes wearing long sleeved shirts and long pants, using insect repellent and staying in screened-in or air-conditioned rooms.

The viremia period for Zika infection is about one week. This virus will have been removed from the body’s circulation after this short period. Any pregnancy after this interval is unlikely to be harmed by Zika virus.

PELVIC FLOOR INJURY – A PRICE TO PAY FOR VAGINAL BIRTH?

Pelvic floor (Levator ani) injury occurs in 3 of 10 vaginal deliveries and often results in pelvic floor dysfunction including pelvic organ prolapse and incontinence.

The pelvic floor muscles is consist of three main muscle groups: the puborectal, the pubococcygeal, and the iliococcygeal. The main function is to support the vagina and pelvic organs, and maintenance of urinary and fecal continence.

During vaginal childbirth, the opening of the genital hiatus distends substantially to allow the passage of the fetus. This stretches the pelvic floor muscle greater than 3 times their original length, thereby putting strain on the muscles and can result in damage.

In addition, during the second stage of labor as the fetal head descends, excess stretch and distention of the muscles result in stretch and distention of the nerve to the levator ani. Prolonged stretching of this motor nerve has the potential to permanently damage the nerve, leading to laxity or sagging of one or both sides of the Iliococcygeus muscle.

 The above two labor related mechanisms have the potential to cause significant injury to the pevic floor muscle attachments and nerve supply, leading to an increase risk of urinary and fecal incontinence and future development of pelvic organ prolapse (POP).

 The prevention for pelvic floor dysfunction may be reduced by pelvic floor education and exercises during and after pregnancy. In one study, women who received pelvic floor therapy from 20 weeks’ gestation were less likely to report urinary incontinence in late pregnancy, at 3 months and 6 months postpartum. It appears that routine pelvic floor education or referral to pelvic floor physical therapy during the intrapartum and postpartum period may be beneficial, especially in high-risk patients.

 

Reference

  1. Dietz HP. Pelvic Floor trauma in childbirth. Aust N Z J Obstet Gynaecol. 2013;53:220-230.
  2.  Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106:707–712.

CERVICAL MUCUS MONITORING- A SIMPLE WAY TO ENHANCE PREGNANCY CHANCE

The fertile window period is defined as the 6-day period ending on the day of ovulation (Brosens 2006). Intercourse is mostly likely to result in pregnancy when it occurs within this period.  The peak fecundability was observed when intercourse occured within 2 days prior to ovulation (Wilcox 1995).  It is desirable to predict the fertile window period and ovulation, to optimize conception rate but can be challenging with the available methods.  Amongst the methods available, include calendar method, basal body temperature (BBT), urinary LH detection, cervical mucus monitor, urinary estrogen metabolites and transvaginal ultrasound scan for follicle tracking.

Cervical mucus monitoring (CMM) is a prospective and inexpensive method to detect fertile window.  It was found to be as good as or better than BBT or urinary LH monitoring to predict the day-specific probabilities of conception (Bigelow 2004).  The cervical mucus is observed at the vulvar for its appearance and sensation.  Type 1 and 2 are typically present at the beginning of menstrual cycle.  They are associated with a dry (type 1) or damp (type 2) sensations at the vulva.  Type 3 is typically thick, creamy and whitish or yellowish mucus with damp sensation.  The type 4 cervical mucus is transparent, stretchy or elastic (raw egg white) with wet or slippery sensation.  Intercourse at this period is associated with a high conception rate.

Hoeker et al., observed that CMM when applied consistently resulted in increased fecundability. It is more effective for timing of intercourse than the calendar method, as it allows identification of onset and duration of fertile window to be determined prospectively.  It reduces the overall time to pregnancy.

CMM is a free, self-directed method used to detect fertile window prospectively.  When applied consistently, it reduces the interval to conception and enhances fecundity.

Note:

Fecundity : Ability to conceive or to produce offspring

Reference:

  1. Bigelow JL et al., Human Reprod 2004
  2. Brosens I et al., Sex Reprod Menopause 2006
  3. Evans-Hoeker E et al., Fert Steril 2013
  4. Wilcox AJ BMJ 1995

PRENATAL VITAMINS: A REVIEW OF THE LITERATURE ON BENEFITS AND RISKS OF VARIOUS NUTRIENT SUPPLEMENTS

Most pregnant women take a daily prenatal vitamin, but advising the patient can be difficult because so many different formulations are available.
Prenatal vitamins generally contain a variety of vitamins and minerals and may be similar to multivitamins used outside of pregnancy, with some notable differences. Some of these vitamins have been studied directly (eg, folic acid), and their recommended allowance comes from sound evidence. But for most vitamins, data are limited, and for multivitamins (also referred to as multimicronutrient supplements), study results can be biased by confounding variables.

“INCREASED RISK OF NEURAL TUBE DEFECT” – WHAT DOES IT MEAN?

Is there something wrong with my baby?

The above blood result does not necessarily indicate that there is something wrong with your baby.  The screening test, which is designed to assess if there is a greater than expected chance (an increased risk) of the fetus having a neural tube defect.  A positive result serves as a guide that there is a small chance (1 in 30) the fetus might have a neural tube defect. It does not mean that your baby definitely has a neural tube defect.

At this stage, the only answer is that one should consider further testing.  In 9 out of every 10 pregnancies reported as being at increased risk of neural tube defect, continue to deliver a normal healthy baby without a neural tube defect

 What is a neural tube defect?

Neural tube defects (NDT) are rare but serious abnormalities, which occur in the early development of the fetus.  It is not known what causes them. The two most common types are anencephaly (not compatible with live) and spina bifida.

 Further assessment to confirm the diagnosis

A detailed ultrasound scan to assess the fetal head and spine enable the diagnosis of NTD.  This is a safe procedure with no residue effect on the fetus.  It examines the physical features (structures) of the fetus.  If the fetal head and spine look normal on ultrasound scan, the chances of a NTD is very low. The ultrasound scan can detect fetus with NTD most of the time (sensitivity over 90%).

 Must I have further testing?

The option of further testing (detail ultrasound scan) following the result of increases risk for NTD is by choice.  It is helpful to discuss with the doctor looking after the pregnancy before making an informed decision.