The Dangers of Middle-Aged Pregnancy and Childbirth

"Because my own 'mature pregnancy' was so tough, my husband and I now tell our young friends: If you want to have a child, do it early!" So says 43-year-old Shuhui, whose name has been changed in this article.

Shuhui married before 30, which is rather early for modern people. At first she and her husband, both of whom worked for a famous media outlet, had no plans to have children.

For nearly nine years, they happily spent their lives as DINKs (double income, no kids). That changed when she was 38. "My mother-in-law was on her deathbed, and she was fretting that my husband and I didn't have any children yet," Shuhui recalls. "Losing a close relative caused us to have a change of heart. It was then that we started seriously to consider having a child."

Yet the difficulties and dangers of giving birth at that late age were far beyond what Shuhui had imagined. Although she quickly and naturally became pregnant, her joy didn't last more than two months, as she had a miscarriage. "The doctor said that the egg that had become impregnated wasn't of high quality, so that there was no chance it could grow into a child."

With modern people having fewer children and putting off having children until they are older, the number of births in major hospitals keeps declining. Since all healthy newborn children are precious treasures, the fertility problems that older women face are worthy of our concern.

Hapless cherub

After that first miscarriage, the couple's rotten luck was far from over. The following year Shuhui got pregnant again, and in the 16th or 17th week, she underwent amniocentesis at her doctor's suggestion. "Much to our surprise, we had 'hit the jackpot.' The child I was carrying had Down's syndrome!"

Whether or not to carry on was a difficult decision for Shuhui and her husband to make, but taking into consideration that Taiwan lacked a comprehensive care system, they reached the difficult decision to end the pregnancy. In the 19th week, Shuhui went to National Taiwan University Hospital where they worked to induce childbirth for five days before the fetus with Down's syndrome was expelled, stillborn.

"When I came home, I cried for a week, constantly feeling that I had wronged the child. It wasn't until I was able to soothe myself with the thought that the child had become an angel that I was slowly able to dispel my sadness."

At 41 Shuhui became pregnant again and once more underwent amniocentesis. Worried that her hopes would again be dashed, she couldn't sleep during the two weeks before the results came back. But fortunately this time the results brought joy, and eventually she would give birth to a healthy, lively daughter.

Chromosomal disorders

Among all the risks that older mothers face, becoming pregnant with a Down's syndrome child, as Shuhui did, is without a doubt an older prospective mother's greatest fear. It's a blow that's hard to bear.

Hsu Jenn-jeih, who is one of Taiwan's best known experts about high-risk pregnancies and the director of obstetrics at Chang Gung Memorial Hospital in Taipei, says that older prospective mothers have higher rates of babies with chromosomal disorders largely because their ovaries function worse and the quality of their eggs is uneven. As a result, after eggs are inseminated, problems are more likely to occur during the process of cell division. "It's like how copies grow less clear the more you use a copier-how the smudging, missing bits and blemishes grow more numerous. These small errors are reflected in the chromosomes, and they often represent irreversible medical conditions!"

There are several birth defects caused by chromosomal abnormalities that disproportionately affect the children of mothers who become pregnant late, including Down's syndrome (trisomy 21, which is caused by having an extra third copy-or trisomy-of chromosome 21), Edwards syndrome (trisomy 18, in which the fetus has multiple organ disorders and serious developmental delays), and Patau syndrome (trisomy 13, in which the fetus often suffers from holoprosencephaly, cleft lips and palates, and sometimes even a lack of eyes). All these chromosomal abnormalities are most common among the children of mothers who become pregnant late. They are known collectively as "trisomy abnormalities," and among them Down's syndrome is most common.

According to statistics from the American Society for Reproductive Medicine, 0.05% of children conceived by women at age 20 have Downs' Syndrome. That figure rises to 0.1% among women age 35, 1% among women who conceive at 40, and 5% among women who conceive at 45.

About 60% of embryos afflicted with these abnormalities are naturally eliminated early in the pregnancy by miscarriage (such as the first time Shuhui was pregnant). This is a mechanism that nature uses to weed out the weak and ensure that the fittest survive. Consequently, when older women have a lot of bleeding shortly after becoming pregnant, doctors usually adopt an approach of wait and see. They usually don't aggressively recommend measures to prevent miscarriage. As for the 40% of cases that don't result in miscarriage, fetuses can be screened by amniocentesis.

Although older mothers have a higher rate of babies with these chromosomal abnormalities, the occurrence of other developmental defects among newborns, including congenital heart disease, congenital metabolic disorder, hypothyroidism, galactosemia, glucose-6-phosphate dehydrogenase deficiency, as well as nervous disorders such as autism and ADHD, don't seem to increase among older mothers.

Hsu emphasizes that because most older mothers abide by their doctor's orders and undergo amniocentesis, the number of births with chromosomal disorders among them has fallen dramatically. In fact, it is now substantially lower among older than among younger women. Consequently, in many nations, including Taiwan, young pregnant women are recommended to come in early in the pregnancy for a non-invasive, less expensive form of Down's Syndrome screening-so as to reduce the potential for future regrets.

Ill while pregnant

Apart from the risk of giving birth to a baby with chromosomal disorders, these older mothers-to-be are more likely than younger pregnant women to suffer their own internal illnesses.

Hsu explains that people are at their physical peak at 25-35, and then they start to go gradually downhill. Their metabolisms also worsen. Becoming pregnant may naturally trigger high blood pressure, diabetes and other chronic conditions. What's more, in older pregnant women the cardio-respiratory and endocrine systems function worse than in younger women, so the former tend to have higher rates of breathing difficulties, including hyperventilation.

Because many older pregnant women used artificial reproductive technology to get pregnant, they more frequently have twins and multiple births. When they do carry more than one fetus, it puts an additional burden on the mother's heart and lungs, so that they suffer from high blood pressure and other medical conditions at a rate several times higher than other pregnant mothers of advanced age. Preeclampsia, which Betty Wu suffered from, is one of the most common illnesses afflicting older pregnant mothers who carry multiple fetuses.

Xu points out that preeclampsia happens when the cells of the placenta begin to emit a substance about which the medical community still knows very little. It makes their blood vessels contract and continually raises their blood pressure. Clinically, it often results in protein in the urine and unusual swelling throughout the body.

It's a medical condition that harms both the mother and the child-and it's often particularly hard on the mother. When the mother's blood pressure approaches extremely high levels, it may result in cramps, internal bleeding and strokes, and the functioning of the liver, kidneys and lungs can be affected. From the child's end, because the functioning of the placenta is poor, the baby can't absorb sufficient nutrients and oxygen and consequently often has developmental issues. In extreme cases it can even be life threatening.

The best way of resolving preeclampsia is to remove the culprit-the placenta-via childbirth. Consequently, if the mother's condition becomes critical, and the preeclampsia can no longer be controlled via regularly prescribed drugs, the doctor will usually induce an early birth. An example is when Wu had an urgent caesarian section in the 29th week. Because these babies born prematurely are very low weight and are developmentally delayed, they more easily develop jaundice and cardio-respiratory problems. They must be carefully observed in the incubators of intensive-care wards.

Apart from preeclampsia, gestational diabetes is also common among the babies of older pregnant women. Xu points out that when pregnant women have elevated blood sugar levels during their pregnancy, their babies may have "excessive nutrition" over long periods, so that they develop macrosomia or "big baby syndrome" (which is usually defined as giving birth to a child over four kilograms), and they often have ailments related to low blood sugar or electrolyte imbalances. If their blood sugar is low for too long, it can harm the development of the baby's brain and nervous system. Consequently, obstetricians pay special attention to "big babies."

Hsu stresses that older pregnant women with histories of diabetes or high blood pressure among close relatives are at much higher risk. During the course of their pregnancies they must be highly vigilant not to let their weight increase too fast. It's best not to gain over 15 kilograms during their pregnancy, so as not to trigger "disease genes."

"Pregnant women who have gestational diabetes have a greater chance of becoming afflicted with adult-onset diabetes down the road. Consequently, they should continue to be careful about what they eat and drink after childbirth, and have blood-sugar tests at regular intervals," Xu says.

Be fully prepared

Because older pregnant women more often encounter complications during pregnancy, and because their skeletal and muscular systems are not as adaptable as those of younger women, when they give birth to their first child they often have difficult and prolonged labors that require caesarian sections to protect the health of the mother.

And apart from C-sections for these medical reasons, older expectant mothers are also more nervous and worry more that they won't have enough strength to give birth conventionally. Consequently, these older women are five to six times more likely to have C-sections than younger mothers.

Older pregnant women have a high chance of stillbirth. Fortunately, many problems can be controlled via modern medical science. According to the Bureau of Health Promotion, 2.67% of pregnant women ages 40-45 whose pregnancies go beyond 20 weeks have stillbirths, and the figure rises to 3.77% for women ages 45-49. Although those numbers are two to four times higher than the 0.81% among women ages 25-29, the number of stillborn children still represents a small minority of older women's total births.

So as to reduce the dangers of childbirth among older women, doctors say that it is best for expectant mothers in this age group to increase the number of times they get screened, so that they can keep a close watch on the health of their child during the entire course of their pregnancy. (The National Health Insurance program pays for up to 10 screenings, but doctors recommend 12-14 for older women.) What's more, it is recommended that older pregnant women choose a general hospital for screening and giving birth that includes other departments and specialists. Then, if one has the misfortune of coming down with diabetes, high blood pressure or other conditions, one can immediately obtain the most appropriate care.

As for working or getting through everyday life, one must know one's limits. By all means, older pregnant women should not overexert themselves, and they should heed doctors' orders to rest. Xu says that many older mothers are highly accomplished career women. Even if they discover that their blood pressure is high and they have an irregular pulse (cardiac arrhythmia) or even such signals as bleeding and loss of fetal movement, sometimes they still won't stop working, and they don't respect their doctor's orders to get more rest and take it easy. It's dangerous behavior.

"Challenging your body's limits and burning the candle at both ends may be all right for young people, but older pregnant women lack the physical wherewithal to do this. Ultimately, if they end up losing their baby, they'll spend the rest of their lives regretting it."

The advantages of maturity

However, "being a step slower than others in becoming parents" is not without its advantages. These parents typically have more financial resources, and the husband and wife tend to have a more stable relationship. And it's likely that they will be more patient, loving and wise when confronting the trials and tribulations of childhood.

"In the long term, the future development of this group of children will be more outstanding than the babies of younger parents." Various obstetricians, including Hsu Jenn-jeih and Liu Chi-hong, make the same observation.

The trend toward marrying and having children later seems irreversible among modern people. How to go about conducting proper health education on this topic and helping older pregnant women get through the tribulations of pregnancy, so that they can bring fully into play their advantages as parents, is a goal that all of Taiwan society should strive for.

The rate of Down's syndrome depending upon the age of the mother