Late pregnancy is a gestation that has occurred in a woman whose age exceeds 35 years. In addition to the characteristic signs of a normal pregnancy, weakness and fatigue are more pronounced in patients, swelling of the lower extremities, pasty face, headaches, dizziness attacks, heaviness, painful sensations in the lower abdomen occur more often. The likelihood of complications increases. Late pregnancy is diagnosed by gynecological examination, immunological express methods, ultrasound of the uterus. Drug therapy with antibiotics, hormonal, tocolytic, antiplatelet and other drugs is used only if there are indications.
ICD 10
Z35.5 Z35.9
General information
Since the late 1970s and early 1980s, the number of women who decided to give birth to a child at the age of 40 and even later has been rapidly increasing in the world. By the beginning of the 2000s, the number of 35-39-year-old women in labor increased by 90%, and the frequency of conception at the age of 40 and over — by 87%. In some cases, late pregnancy is the first. The relevance of proper maintenance of such gestations is due to the increased risk of obstetric complications and decompensation of chronic diseases, which are more often affected by middle-aged women. However, the birth of a late first or second child has a number of positive aspects. Usually, with increasing age of the patient, the level of stress experienced during pregnancy and in the postpartum period decreases, which has a beneficial effect on the physical, emotional and intellectual development of the child. According to research in the field of obstetrics, in women who gave birth in mature years, the incidence of endometrial cancer decreases by 32-45%, ovarian cancer — by 16%. They have menopause later, menopause is milder, osteoporosis is less pronounced.
Causes
The optimal period for conceiving and bearing a healthy child is the age range from 18 to 35 years. It is during this period that a woman has maximum fertility, and her physical form allows her to give birth with minimal risk of obstetric and extragenital complications. However, there are a number of biological, medical and social prerequisites that contribute to the onset of pregnancy at a later age:
- Infertility. Conception and gestation of the fetus are prevented by abnormalities of the development of reproductive organs, ovarian diseases (chronic oophoritis, polycystic, sclerocystic), fallopian tubes (salpingitis, hydrosalpinx, adhesions, volumetric processes), uterus and its cervix (endometritis, polyps, submucosal fibroids, cervicitis, cervical insufficiency), adhesions in the pelvis. Modern methods of treatment and reproductive technologies allow pregnant patients who previously could not conceive a child. In some cases, fertility recovery is prolonged, gestation occurs after 35 years.
- Postponing pregnancy. Some women deliberately postpone plans to create a family, childbearing to a later age because of the desire to build a career, reach a more stable and high financial and material level, “live for yourself”. An increase in life expectancy, expansion of opportunities for education and career growth, emancipation, changing public attitudes towards the role of women, modern means and methods of contraception play a certain role. As a result, in many developed countries, the average age of gestation is increasing (up to 30 years or more), as well as the number of late first-time births.
- Unplanned pregnancy. By the age of 35-40, most women have solved family planning issues, conception may be the result of neglect of contraceptives or the ineffectiveness of previous methods of prevention. Thus, menstrual cycle disorders caused by the coming menopause reduce the effectiveness of the physiological method of contraception based on the calculation of the date of ovulation. After 35-40 years, female fertility deteriorates significantly, but this does not indicate the development of infertility. Over 70% of pregnancies that occur in late reproductive age end with medical abortions.
Statistics show a steady increase in the percentage of divorces and the number of women remarrying. In such circumstances, the decision to give birth to a “late” not the first child may be dictated by the desire to strengthen a new family. Some pregnancies of mature age are the result of a conscious refusal of contraception, dictated by religious views and traditions of the family.
Pathogenesis
Late pregnancy develops in the same way as in younger patients. However, natural age-related changes in the female body and pathological disorders characteristic of adulthood affect the course of its individual stages. Since the prevalence of inflammatory diseases of the genital organs increases by the age of 35, leading to a deterioration in the patency of the fallopian tubes, it is possible to disrupt the implantation of a fertilized egg with the formation of ovarian, abdominal, tubal pregnancy. Morphological changes in the endometrium associated with invasive interventions, inflammation, the presence of polyps, submucous nodes, contribute to the introduction of the fetal egg in the cervix. Often occurring hormonal imbalance causes the threat of termination of gestation and becomes a prerequisite for disruption of normal contractile activity of the myometrium. Age-related decrease in the elasticity of soft tissues increases the likelihood of their ruptures.
Symptoms
The possible onset of gestation in mature women may be indicated by the appearance of morning sickness, vomiting, aversion to certain odors, a change in food preferences, a violation of appetite. As at the beginning of a normal pregnancy, patients complain of drowsiness, mood swings, irritability, general malaise, attacks of dizziness. Urination becomes more frequent in them, the mammary glands become rough and more sensitive, hyperpigmentation of the areolar region, the white line of the abdomen, pigmented spots on the face appear. The more likely symptoms of pregnancy are the absence of menstruation, colostrum, a noticeable increase in the circumference of the abdomen. From 16-18 weeks, a woman begins to feel the movement of the fetus, from the second trimester, parts of it can be felt through the abdominal wall.
Complications
The risk of complicated gestation in older patients is 2-5 times higher than in 20-30-year-olds. 35-39 years is the age peak of multiple pregnancy, which exerts an increased load on a woman’s body even in young pregnant women. Violation of the patency of the tubes and the structure of the endometrium due to early invasive interventions and diseases of the reproductive sphere increases the likelihood of late ectopic pregnancy. In age—related pregnant women, gestosis is 2.7 times more common, including in the form of the most severe form — preeclampsia, 4.5 times — gestational diabetes, 3.2 times – apparent diabetes requiring insulin therapy.
Due to hormonal imbalance, somatic disorders, an increase in the frequency of genetic defects and chromosomal aberrations in the fetus (from 0.08% in 25 years to 5% by 45 years), the probability of spontaneous miscarriage increases by 3 times and reaches 33%. Premature birth in women with late gestation occurs 4 times more often, and sometimes they are caused artificially due to the identified complications. As a result of the occurrence of chronic placental insufficiency, the frequency of birth of underweight children increases by 2 times. More large fetuses are born (mainly in patients with diabetes mellitus).
Since in the third trimester, pregnant women over 40 years of age have an eight-fold increased risk of placental abruption, antenatal fetal death is 50% more common than in young women. In childbirth, patients of late age often experience weakness of labor, ruptures of the cervix, vagina, perineum, hypotonic bleeding, DIC syndrome, acute extragenital pathologies (myocardial infarction, stroke, retinal detachment). In 40% of cases, 35-40-year-old pregnant women undergo cesarean section, after reaching 40 years, this figure reaches 47%. With late pregnancies, maternal mortality is doubled.
Diagnostics
The tasks of the diagnostic stage are confirmation of the fact of gestation, early detection of possible fetal abnormalities, dynamic monitoring of its development, determination of possible risks during late pregnancy. A comprehensive examination includes such physical, laboratory, instrumental diagnostic methods as:
- Gynecological examination. The probable gestation is indicated by cyanosis of the mucous membrane of the vagina and uterine cervix. With bimanual palpation, the shape, size, consistency of the uterus are changed, pathognomonic symptoms are determined (Gegara-Horvitsa, Snegireva, Piskachek). As pregnancy progresses, during the examination on the chair, the condition of the uterus is assessed, pathological contents are sometimes detected in the vagina, indicating complications.
- Immunological pregnancy tests. The use of modern highly sensitive rapid diagnostic methods based on the determination of chorionic gonadotropin in urine or blood serum makes it possible to confirm the fact of gestation with a high probability. The advantage of immunological tests is to obtain fast results and the possibility of carrying out even at home when the next menstruation is delayed.
- Ultrasound of early pregnancy. The echographic method makes it possible to visualize the fetal egg in the uterine cavity, starting from 3-4 weeks of gestational age, although more often the examination is carried out between 6-10 weeks. Ultrasound is recommended for all patients with suspected pregnancy. Subsequently, ultrasound examination is used to control the development of gestation (ultrasound screening of the 1st, 2nd, 3rd trimester), fetal condition (fetometry) and uterus.
- Diagnosis of developmental abnormalities. Taking into account the risk of chromosomal aberrations and genomic defects in late gestations, noninvasive prenatal diagnostic methods are used, with the help of which fetal DNA circulating in the blood of a pregnant woman can be examined. The standard test for 5 chromosomal abnormalities and the extended test for 10 are highly informative. According to the indications, invasive studies are carried out — amniocentesis, chorion biopsy, cordocentesis, placentocentesis.
To assess the course of gestation and the condition of a woman in dynamics, the indicators of a general blood test, a general urine test, data from biochemical studies (blood glucose levels, etc.) are compared. If necessary, laboratory tests are prescribed to monitor pregnancy (determination of levels of placental lactogen, placental growth factor, free b-hCG, free estriol, trophoblastic β-1-glycoprotein). To exclude infections leading to intrauterine fetal damage, the pregnant woman is examined for a TORCH complex. The patient is consulted by a therapist, an ophthalmologist, a neurologist, according to indications, a urologist, a cardiologist, an endocrinologist, an infectious disease specialist, a pulmonologist and other specialized specialists. Late pregnancy is differentiated with early menopause, uterine fibroids, amenorrhea against the background of ovarian insufficiency and other diseases that disrupt the menstrual cycle.
Management of late pregnancy
The task of medical tactics in the management of pregnant patients of mature age is to prevent possible complications (both obstetric and extragenital) and, in the absence of contraindications, planned preparation for natural childbirth. Medical support of late pregnancy involves careful monitoring of the patient’s health, correction of her lifestyle, therapy of concomitant disorders. Usually , age -related pregnant women are recommended:
- Sufficient rest and dosing of loads. To reduce the threat of interruption of late gestation, it is important to limit the performance of heavy physical work, lifting weights, stressful situations. Normalization of night sleep and rest during the day positively affects the course of pregnancy. Sedative herbal remedies are used for insomnia.
- Correction of the diet. Nutrition should be sufficient in calories and balanced in composition, contain foods rich in protein, calcium, iron, vitamins. In the autumn-winter period, it is possible to use vitamin and mineral supplements. When choosing a diet, it is necessary to take into account the recommendations of specialized specialists.
- Preparation for childbirth. Performing exercises from special physical therapy complexes for pregnant women, classes in yoga, aqua aerobics, swimming, pilates groups increase a woman’s physical readiness for labor activity. According to the observations of obstetricians and gynecologists, in such patients, childbirth is faster, easier, with a lower frequency of complications.
Medications of different groups (antibiotics, antispasmodics, tocolytics, antiplatelet agents, peripheral vasodilators) are used according to indications, taking into account their possible effect on the fetus. Sometimes the appointment of hormones is required to preserve gestation. Although the frequency of cesarean section deliveries in pregnant women of late reproductive age increases, with proper prenatal preparation, the absence of serious obstetric contraindications (narrow pelvis, large baby, oblique or transverse fetal position, placenta previa) and severe somatic disorders, natural childbirth is preferable.
Prognosis and prevention
In healthy pregnant women aged 35 years and older, with well-organized medical supervision, gestation in 90% of cases proceeds without complications, can be completed in a natural way. For preventive purposes, women planning a late pregnancy are recommended pre-pregnancy training with a visit to an obstetrician—gynecologist, therapist, oculist, according to indications – other specialists. The foci of chronic infection are sanitized, karyotyping is carried out to exclude chromosomal abnormalities in the fetus. After conception, early registration in a women’s clinic, the choice of an optimal pregnancy management program, and conscientious implementation of medical recommendations are important.
