Pregnant after 35

placenta insufficiency due to advanced maternal age

Talking with my OB at today's appt about chances of being induced and options. He tells me that due to my AMA I will not be allowed to go past 39 weeks. So I ask what that is about. He tells me that with women over 35 their placenta tends to stop working sufficiently past 39 weeks. Really? I never heard of that. Long story short, OB will induce at 39 weeks based solely on my age. I will be 36 when I deliver. Wondering if anyone else was told this by their OB. Any experience dealing with this? Is my OB induction happy?

Re: placenta insufficiency due to advanced maternal age

  • I haven't given birth yet but at the age of 40 my OB keeps telling me I'll go until 40/41 wks. My sister went to 40 wks at the age of 42. I have heard that you should not go too far past your due date whether your AMA or not because of decreased plancental function, but I also think your Dr. is just being very conservative.
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  • My OB says he won't let me go past 41 weeks.  I'm not actually sure of the reasoning.  I asked him about going earlier due to ama but he said its not necessary.  I had read about not letting ama women go past their due dates because the chance of stillbirth goes up.  As far as the placenta issue my OB did say the same thing about it possibly not working sufficiently.  Because of this I will be having twice weekly u/s starting at 36 weeks.  Sounds like your OB is being cautious.  I can tell from this board that it really just depends on your OB because they all handle these things differently.

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  • My OB wasn't going to let me go past 40 weeks - but I am nearly 40.  
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  • I think "tends to stop working sufficiently" is overstating it.  I think it is more that there is a greater risk that it does.  I'm having twins so I'm doing NSTs and getting ultrasounds that check the placenta as I think twins presents another level of risk that the placenta deteriorates.

    On an ultrasound, they can check the extent to which the placenta is calcifying.  Between that and monitoring growth, that should give them a good idea if something isn't working right.  If you are really uncomfortable with an induction at 39 weeks, you could ask for those kinds of scans and see what they say.   

  • My doc said he doesn't make changes in care due to AMA until after age 38. I think this is very conservative, especially without any signs of problem, like slow or decreased growth or fluid.
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  • I'm 38 and my OB is treating me like any other pregnant woman-- except for discussing genetic testing when I was in my 1st trimester.
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  • Like the others have said, it's my understanding that the risk of placental insufficiency does increase with age.  I'm not sure what my current OB's stance on this is, b/c we aren't there yet.  My OB who delivered my daughter never brought it up.  I think your's is being very conservative.
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  • Your OB is seriously over-conservative and working with out-dated practices.  Although placenta does degrade over time, and there is a risk of it happening sooner with older moms, routinely inducing at 39 weeks is insane, absurd, and about a million other adjectives that mean crazy.  My guess is, this is the type of OB that also thinks episiotomies and forceps are still standard practice.

    Run screaming to another OB or better yet, a midwife, immediately. 


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  • imageELF4321:

    Your OB is seriously over-conservative and working with out-dated practices.  Although placenta does degrade over time, and there is a risk of it happening sooner with older moms, routinely inducing at 39 weeks is insane, absurd, and about a million other adjectives that mean crazy.  My guess is, this is the type of OB that also thinks episiotomies and forceps are still standard practice.

    Run screaming to another OB or better yet, a midwife, immediately. 

    I completely agree with this. I asked my MW this week if there was any, y'know, actual scientific EVIDENCE that older moms may have placenta degradation issues, and she said there was, but that on the other hand, she had recently gone to support another patient, a 17 y/o smoker having a c-section after a totally crappy NST/BPP showed the baby was not doing well, and her placenta looked terrible. She (my MW) went on to say that good nutrition and exercise were the best ways to keep the placenta working well, and that since I am eating well and exercising, I should have nothing to worry about. Your OB sounds like he is stuck in the Dark Ages.

    I have been meaning to go do my own Cochrane search on placenta degradation in AMA pregnancies but haven't gotten around to it yet.

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  • This is a second hand story, but my good friend gave birth at 42 weeks last year. She was 42 years old when she delivered a healthy baby girl. 
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  • I personally think that sucks, but it varies by OB and IS an actual thing. Being older CAN lead to degradation of the placenta sooner, but proper monitoring can help with that.

    I was 35 when I had DS1 and went to 42 weeks. I was 38 when I had DS2. One of my OB's said she wouldn't let me go past 40 weeks. Another said, 'what about your age? Because you're so young?'  LOL

     It was a moot point as he cameust shy of 40 weeks, but they'd been monitoring me with u/s's - not even NST'S yet - and everything was fine so I think I would have pushed back against being induced at 40 weeks just because of my age.

  • Change OB's now. That's a load of hooey. I was 40 when I gave birth, and had other high risk issues (auto immune issues, clotting factors in my blood) and was still not advised to have an induction until 9 days past my due date when I showed no signs of advancing labor at all (baby hadn't dropped, etc). No one ever said thing one to me about any placenta issue unless I went past 43 weeks, and they would have waited longer to induce had I been showing any signs of labor whatsoever. 
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  • I was 36 with my first daughter, and my OB didn't schedule my induction until I would be 42 weeks.  Luckily I went into labor on my own at 41.5, but she only said that she would not let me go past 42 weeks.  Now at 38 this OB is treating me like any other pregnant woman, and hasn't said anything about induction early.  The only thing that they pushed was genetic testing.
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  • My OB practice schedules an induction for any healthy mother, regardless of age, if she has still not given birth by week 41.  It is not an age-related decision as far as I can tell.
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  • My concern with going too long would be meconium in the baby's lungs before it would be placental insufficiency. The former is more likely than the latter.

    I think it would be worth having the conversation with you OB-- why do you think my age is that big an issue (you're younger than lots of the women here, for example, barely over the 35 mark) for me? Why wouldn't you simply continue to monitor me to make that determination as needed? What else are you envisioning for my birth (just to make sure he's not still into forceps!)?

    And then, if you're not comfortable with his answers and/or how he handles the conversation (I could never go to a doctor who didn't give me any respect and believed s/he was in complete control of my choices), then move to another doctor before you are much further along...
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  • I was 36 when I delivered my second and because of low platelet levels, I was given the option to induce at 39 weeks.  My doctor said if I were his wife, he wouldn't let me go past 39 weeks because of my age.  I think this is one of those things where different OBs will give you a different answer.
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  • While I agree with most others that you're OB sounds incredibly conservative considering you are only 36, there are reputable studies that indicate the chance of fetal death is ~3x higher for women over 40 after 40 weeks gestation(see study result statement below).  I don't believe that they linked it to any one cause ie placental insufficiency.  To put it in perspective though, the risk of any fetal death is small so a 3x greater chance is still very low.   Since you are not >40, I believe your risk is still similar to those <35. 

        "The risk of fetal death was 1.4 times higher in women 40-44 years old than in women aged 20-24 years in midpregnancy but 2.8 times higher at term. In term pregnancies the relative importance of maternal age increased by additional pregnancy weeks. In gestational weeks 42-43, the crude risk was 5.1 times higher in mothers 40 years old or older. In the recent period, the elevated risk of fetal death in elderly mothers at term has been attenuated."

    I was 40 when I delivered DS.  My OB would not have let me go past 40 wks (but luckily the July 4th holiday prevented a scheduled induction until I was 40 wk 5 day).  I had NSTs 2x a week for the last month of my pregnancy and an extra ultrasound at ~36 weeks to check on things.  I have a sister and sister-in-law who both lost their children in utero after 36 weeks and they were not AMA.   This knowledge coupled with the fact we had tried 3 years to get pregnant made me extremely sensitive and probably more agreeable to an induction on my OB's advice. FWIW, I had a completely uneventful pregnancy and was still exercising until the day before induction so there was no indication that I or the baby were in distress.

    I would discuss further with your OB and see if there is an alternative for more monitoring towards the end of your pregnancy that would allay his concerns for your baby's health.   

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  • huh, i will almost be 41 when i deliver and my ob said he won't even schedule my csection til after 39weeks. 
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  • imagedanieleandwayne:
    I'm 38 and my OB is treating me like any other pregnant woman-- except for discussing genetic testing when I was in my 1st trimester.

    This was me when I was pregnant at 38.  They monitored me closely once I hit my due date.  I was going to be induced 11 days after my due date.  LO came on her own the day before.  In my area, many women over 35 are having babies, so it is not considered a big deal.  I had the genetic testing done, but other than that was not treated any differently.

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  • I don't agree with your doc. I'd do some research and ask some questions. I know many folks who delivered over 36 and went into labor naturally. 

  • imagegenekelly:

    While I agree with most others that you're OB sounds incredibly conservative considering you are only 36, there are reputable studies that indicate the chance of fetal death is ~3x higher for women over 40 after 40 weeks gestation(see study result statement below).  I don't believe that they linked it to any one cause ie placental insufficiency.  To put it in perspective though, the risk of any fetal death is small so a 3x greater chance is still very low.   Since you are not >40, I believe your risk is still similar to those <35. 

        "The risk of fetal death was 1.4 times higher in women 40-44 years old than in women aged 20-24 years in midpregnancy but 2.8 times higher at term. In term pregnancies the relative importance of maternal age increased by additional pregnancy weeks. In gestational weeks 42-43, the crude risk was 5.1 times higher in mothers 40 years old or older. In the recent period, the elevated risk of fetal death in elderly mothers at term has been attenuated."

    I was 40 when I delivered DS.  My OB would not have let me go past 40 wks (but luckily the July 4th holiday prevented a scheduled induction until I was 40 wk 5 day).  I had NSTs 2x a week for the last month of my pregnancy and an extra ultrasound at ~36 weeks to check on things.  I have a sister and sister-in-law who both lost their children in utero after 36 weeks and they were not AMA.   This knowledge coupled with the fact we had tried 3 years to get pregnant made me extremely sensitive and probably more agreeable to an induction on my OB's advice. FWIW, I had a completely uneventful pregnancy and was still exercising until the day before induction so there was no indication that I or the baby were in distress.

    I would discuss further with your OB and see if there is an alternative for more monitoring towards the end of your pregnancy that would allay his concerns for your baby's health.   

    Could you provide a link to that study, please? That looks like proper evidence, but I would like to see more details (sample size, study protocols, etc.).

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  • This is one of the areas where you really need to do your own research. While it is true that stillbirth risk rises with age, the studies I have read do not show that AMA is an independent risk factor for placental insufficiency. Meaning, they don't really know what is causing the stillbirths, just that older women are more at risk. See, https://www.ncbi.nlm.nih.gov/pubmed/15970865

    You need to remember that many women with AMA have confounding health issues that skew the data -- pre-E, GD, IUGR, PPROM, etc. You need to assess your risk on a sliding scale. Are you over 40? What is your BMI? Do you smoke? Have GD? Do you exercise? Do you have any other health issues?

    Unfortunately, from the data I have seen, there just isn't a precise analysis of one's risk given a variety of factors, and it is better to take it on a case by case basis vs. having one-size-fits-all induction protocols for AMA women.

    I am 38, am overweight, and have GD that is controlled by diet and exercise. I will not consent to routine induction at X date, but will use the results of my NSTs, BPPs, my blood sugar numbers, and whether I have any complications (diet-controlled GD has no higher risk of complication than normal pregnancy) to assess the risks as the pregnancy progresses. The fact that Jane Doe down the street had a dead or healthy baby under X, Y, Z circumstances doesn't apply to me, and it won't guide my decisionmaking. I had a healthy 7 lbs. 11 oz. baby at 34 yrs old, with diet-controlled GD, and delivered spontaneously at 41w1d with no complications. But this is a different pregnancy and may have different issues that arise.

    If you have a one-size-fits-all OB, I would think about looking for a different provider who can help guide your decisionmaking with evidenced-based care. 

  • Below are several citations which all reach similar conclusions although their calculation of increased risk varies slightly from my original quote above (which of course I can't locate that specific link at the moment).  The sample size in most of the studies is quite large.  The Jacobsson study (which I think was what my statement was based on) takes data from the Swedish health system which used 1.5 million births from 1987-2001; 31k among women 40-44 and 1.4k among women>45.

    My goal isn't to alarm anyone but to know the facts and make an informed decision on an induction based on discussion with your OB.  As I said, the overall risk of fetal demise is very small so a 3 fold increase is still a very small number.

    N Engl J Med 1995; 333:953-957October 12, 1995  (DOI: 10.1056/NEJM199510123331501)

    Jacobsson et al, American Journal of Obstetrics and Gynecology, VOL. 104, NO. 4, OCTOBER 2004 (doi:10.1097/01.AOG.0000140682.63746.be)

    Obstet Gynecol. 1997 Jan;89(1):40-5.        
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  • The first study cited above says exactly what I said in my post: "Why advanced maternal age is an independent risk factor for fetal death remains unexplained." The second study similarly does not discuss any reasons for fetal demise relating to placental insufficiency, and the third study specifically describes the occurrence as "unexplained fetal death."

    I don't think that anyone is disputing that the stillbirth risk for AMA is increased. The issue is whether the reason for that increase is placental insufficiency and whether induction is the best course of action to prevent stillbirth for all AMA women. That is a large leap, and one that is not supported by any data that I have seen. As I mentioned in my previous post, AMA was not found to be an independent risk factor for placental insufficiency.  

    AMA women are at increased risk for many pregnancy complications that are confounding variables when they do these studies. It's not that placental insufficiency doesn't develop in AMA, but the reasons for it are difficult to tease out of the statistics due to these confounding variables. If you do not have any pregnancy complications, your risks are obviously going to be lower. If you do have pregnancy complications, then one may choose to assess one's individual risk tolerance in conjunction with the data on how the pregnancy is progressing with BPPs, NSTs, growth scans, etc. But, I still don't see how the data you posted supports automatic early induction for AMA as evidenced-based practice. 

  • I have not heard that before. My OB has not said anything about inducing due to possible insufficient placenta. I agree with doing your own research on the matter, and then if you don't feel comfortable with your OB's position, switch OBs. But if you are comfortable and trust your OB, stick with him/her. You have to do what's best for you and your family, regardless of others' opinions. 

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  • imageSea Conquest:

    The first study cited above says exactly what I said in my post: "Why advanced maternal age is an independent risk factor for fetal death remains unexplained." The second study similarly does not discuss any reasons for fetal demise relating to placental insufficiency, and the third study specifically describes the occurrence as "unexplained fetal death."

    I don't think that anyone is disputing that the stillbirth risk for AMA is increased. The issue is whether the reason for that increase is placental insufficiency and whether induction is the best course of action to prevent stillbirth for all AMA women. That is a large leap, and one that is not supported by any data that I have seen. As I mentioned in my previous post, AMA was not found to be an independent risk factor for placental insufficiency.  

    AMA women are at increased risk for many pregnancy complications that are confounding variables when they do these studies. It's not that placental insufficiency doesn't develop in AMA, but the reasons for it are difficult to tease out of the statistics due to these confounding variables. If you do not have any pregnancy complications, your risks are obviously going to be lower. If you do have pregnancy complications, then one may choose to assess one's individual risk tolerance in conjunction with the data on how the pregnancy is progressing with BPPs, NSTs, growth scans, etc. But, I still don't see how the data you posted supports automatic early induction for AMA as evidenced-based practice. 

    You've misunderstood me.  I am not advocating for induction for the OP nor did I say in my original reply that there was evidence linking placental insufficiency to the observed increase in stillbirth for women >40.  I just indicated that there really is an increased risk and that perhaps her OB has that in mind when recommending induction at 39 weeks.  I am saying that she should have a discussion with her doctor to more fully inform her decision on what is best for her. 

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  • imageSea Conquest:

    The first study cited above says exactly what I said in my post: "Why advanced maternal age is an independent risk factor for fetal death remains unexplained." The second study similarly does not discuss any reasons for fetal demise relating to placental insufficiency, and the third study specifically describes the occurrence as "unexplained fetal death."

    I don't think that anyone is disputing that the stillbirth risk for AMA is increased. The issue is whether the reason for that increase is placental insufficiency and whether induction is the best course of action to prevent stillbirth for all AMA women. That is a large leap, and one that is not supported by any data that I have seen. As I mentioned in my previous post, AMA was not found to be an independent risk factor for placental insufficiency.  

    AMA women are at increased risk for many pregnancy complications that are confounding variables when they do these studies. It's not that placental insufficiency doesn't develop in AMA, but the reasons for it are difficult to tease out of the statistics due to these confounding variables. If you do not have any pregnancy complications, your risks are obviously going to be lower. If you do have pregnancy complications, then one may choose to assess one's individual risk tolerance in conjunction with the data on how the pregnancy is progressing with BPPs, NSTs, growth scans, etc. But, I still don't see how the data you posted supports automatic early induction for AMA as evidenced-based practice. 

    You've misunderstood me.  I am not advocating for induction for the OP nor did I say in my original reply that there was evidence linking placental insufficiency to the observed increase in stillbirth for women >40.  I just indicated that there really is an increased risk and that perhaps her OB has that in mind when recommending induction at 39 weeks.  I am saying that she should have a discussion with her doctor to more fully inform her decision on what is best for her. 

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  • imagegenekelly:
    imageSea Conquest:

    The first study cited above says exactly what I said in my post: "Why advanced maternal age is an independent risk factor for fetal death remains unexplained." The second study similarly does not discuss any reasons for fetal demise relating to placental insufficiency, and the third study specifically describes the occurrence as "unexplained fetal death."

    I don't think that anyone is disputing that the stillbirth risk for AMA is increased. The issue is whether the reason for that increase is placental insufficiency and whether induction is the best course of action to prevent stillbirth for all AMA women. That is a large leap, and one that is not supported by any data that I have seen. As I mentioned in my previous post, AMA was not found to be an independent risk factor for placental insufficiency.  

    AMA women are at increased risk for many pregnancy complications that are confounding variables when they do these studies. It's not that placental insufficiency doesn't develop in AMA, but the reasons for it are difficult to tease out of the statistics due to these confounding variables. If you do not have any pregnancy complications, your risks are obviously going to be lower. If you do have pregnancy complications, then one may choose to assess one's individual risk tolerance in conjunction with the data on how the pregnancy is progressing with BPPs, NSTs, growth scans, etc. But, I still don't see how the data you posted supports automatic early induction for AMA as evidenced-based practice. 

    You've misunderstood me.  I am not advocating for induction for the OP nor did I say in my original reply that there was evidence linking placental insufficiency to the observed increase in stillbirth for women >40.  I just indicated that there really is an increased risk and that perhaps her OB has that in mind when recommending induction at 39 weeks.  I am saying that she should have a discussion with her doctor to more fully inform her decision on what is best for her. 

    I get that, but I don't understand the point of a response that doesn't serve to inform about the actual question at hand, but simply serves as another reminder to AMA women that we are at higher risk for pregnancy complications and stillbirths. I think that all of us know that, and hearing it repeated with a bunch of studies, especially towards the end of one's pregnancy, when these fears are often at their peak -- what point does it serve exactly?

    Women are pressured to induce all of the time, and not just the AMA women on this board. It is such an epidemic that ACOG had to remind OBs again recently about their policy against routine inductions before 39w. I am very sensitive to this issue because many inductions --especially in vulnerable populations where fear tactics are often used to scare women into them and make women feel powerless to say no -- are often happening when there is little or no evidence to support them, and without adequate disclosure to the women about the risks involved.

    AMA = higher risk of pregnancy complications and stillbirth. We know this. But, we don't know why that is or that early induction is the best practice for mother and child.    

  • Thank you to all that replied. I have been doing some online research and reading your replies over the last couple days. And my early suspicions that my OB is too conservative for me are confirmed. ELF4321 said something along the lines of "your OB probably thinks episiotomies and forceps are still standard practice." I laughed out loud when I read this because during our heated talk at my last visit forceps were discussed and he still uses them. I will be looking for yet another OB/Midwife. I'm just glad that I'm only 15 weeks along.


  • imagedoodlemonkey22:

    Thank you to all that replied. I have been doing some online research and reading your replies over the last couple days. And my early suspicions that my OB is too conservative for me are confirmed. ELF4321 said something along the lines of "your OB probably thinks episiotomies and forceps are still standard practice." I laughed out loud when I read this because during our heated talk at my last visit forceps were discussed and he still uses them. I will be looking for yet another OB/Midwife. I'm just glad that I'm only 15 weeks along.


    Glad to hear you'll be shopping around for a new doc.  I have a friend who had twins at 42 (her first babies to "stick") and she was induced at 41 weeks.  The placenta does start to "degrade" after a certain time past your due date but that's for EVERYONE regardless of age!!  Good Luck on your MD search! 

     



    image

  • My OB talked to me about this possibility, too, but I will be 42 when I deliver. However, early induction is not a foregone conclusion, instead I will have weekly ultrasounds, from 35 weeks on, to monitor things.
  • Wow, this was a really great discussion. genekelly, thanks for posting those links, and SeaConquest, thanks for your input on the data. And OP, I am glad you are shopping for a new care provider. I think you will be much happier with someone who is not as induction-happy.
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  • I will be 39 when I give birth and my OB will let the baby go past 39 weeks.  I was 36 when I had my daughter and I went into labor naturally at 39 weeks but my OB would have let it go to 41 weeks.  My daughter was healthy and fine inside of me with no apparent dangers.  I am older now and we still have the same plan though my OB thinks since my daughter was early I will probably go early again.  I don't know if I will go early again but we plan to let my body go into labor naturally like it did the first time.  
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