Advanced Maternal Age: Pregnancy After 35
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Sean Daneshmand: When a woman becomes pregnant after 35, she is considered to be of advanced maternal age. But what does that exactly mean? What are some complications pregnant women face as they get older? And what medical options are available to test and treat women of advanced maternal age to ensure the healthiest pregnancy possible? I’m Dr. Sean Daneshmand, Perinatologist with the San Diego Perinatal Center and founder of Miracle Babies. This is Preggie Pals episode 60.
Sunny Gault: Welcome to Preggie Pals, broadcasting from the Birth Education Center of San Diego. Preggie Pals is your weekly online, on-the-go support group for expecting parents and those hoping to become pregnant. I’m your host, Sunny Gault. Would you like to access all of our archived episodes, bonus content after each new show and great giveaways and discounts? Then you need to join our Preggie Pals Club. You’ve heard about it before, we’re going to tell you about it all the time. And you can also get a free subscription to Pregnancy Magazine when you do that. So visit our website PreggiePals.com for more information. And another way for you to stay connected is by downloading our free Preggie Pals app. It’s available on the Android and iTunes marketplace and by subscribing to our monthly newsletter. So we have a packed house today in the studio and I always love it when that happens, because the conversation is always so good. SO we’re going to go around and introduce ourselves. Also, mention as part of your introduction if you are of advanced maternal age and when that lovely transition happened for you. So let’s start things off with Annie. Go ahead.
Annie Laird: My name is Annie. I am 35; I turned advanced maternal age last Tuesday.
Sunny Gault: Congratulations! Welcome to the club.
Annie Laird: Thank you! I know. I’m a government contractor as my day job and then, usually it ends up being a night job, labor doula. But I’m going to be taking a little break from that for baby number three here. The baby is coming in October. Not sure of baby’s gender, we’re…
Sunny Gault: You’re Team Green.
Annie Laird: I’m Team Green. Yeah. This is my third child. I have two older daughters and I’m planning homebirth.
Sunny Gault: Yay! Ok. Kristy?
Kristy Iris: I’m Kristy. I am very young, 41, thank you very much! (Laughs) And I’m due on Labor Day – another… baby has a sense of humor. And it’s a girl, my first, and we’re going to have a birth center birth.
Sunny Gault: Ok. Abby, go ahead.
Abby Finch: Hi! My name is Abby. I also turned 35 while pregnant – that was last month – and I’m a social worker. I’m due October 3rd with a girl. It’s my second girl; I have another girl that will be 2. And I’m planning a birth in the hospital.
Sunny Gault: Ok. And joining us via Skype from Germany is Amy. Amy has been on the show before, but she recently moved to Germany and we’re so happy to still have you as part of Preggie Pals.
Amy Askin: Yay! I’m happy to be here, thanks for having me. I am Amy and I am a blogger and writer and a work-at-home mommy. I had two children when I was advanced maternal age. I was 35 with number two and I just have a 4-month-old and I was 39 when I had her. Both of them were born in… all three of our kids were born in a birth center. And yes, all-natural birthing.
Sunny Gault: Wonderful. And you guys know me, but I do have some news to share with you. This is the first time I’m announcing it on Preggie Pals. I am pregnant, you guys knew that which is exciting. This is our third pregnancy and we have two little boys already. But the big news is last week… was it last week? Gush, the time… Ok. Yeah, you guys are all friends with me on Facebook so you know. We had some big news, we actually went in for our first-trimester screening. I went by myself. My husband was at home with our little boys. He thought that this was a routine screening, just to make sure there’s nothing wrong with the baby. And the sonographer takes one look at me and she’s like, “Oh, twins!” I thought she was joking, I really did. For a good couple of minutes, I was looking around the room for the cameras trying to figure out “Ok, what show am I on? And why did they pick me?”
Amy Askin: You know, Sunny, I didn’t know this.
Sunny Gault: You didn’t know this?! You’ve been moving and stuff, Amy, so you know…
Amy Askin: I’m out of the loop here in Luxembourg.
Sunny Gault: Yes. So this is big news for us. But we are having identical twins.
Amy Askin: How exciting!
Sunny Gault: Yeah. We don’t know the gender yet. Hopefully, we’ll find out soon. Very happy news; I’ve actually always wanted twins my whole life. No twins in the family. It doesn’t really matter if identical, but the only way we were going to get twins is if my eggs split in two randomly and that’s exactly what happened. So anyway, that’s my big news. We will be right back.
[Featured Segment: The Best Pregnancy Apps. Sprout Pregnancy for Expectant Moms!]
Sunny Gault: Alright. So before we kick off today’s show we are going to do a pregnancy app review. It’s something new that we’re doing here on Preggie Pals because we all love our smartphones and our tablets and we’re obsessed with technology in counting contractions and all that fun stuff. So we’re going to review some of the apps that we’ve found that we really like. Today we are focused on an app called Sprout. We’re focusing on Sprout Pregnancy because I think they have a Sprout Baby version too, so if you have your baby you can move on to that app. But this is called Sprout Pregnancy and there’s a free version. And when you first download it actually allows you, I think for 15 days, it automatically upgrades you to their Premium version. And then after the 15 days are over it downgrades you. It’s pretty neat.
You can enter in your baby’s information, obviously your due date or the date of your last period. And then it will kind of configure all that for you. I was a little bummed… not that I expect all these app people to cater to me and my pregnancy, but this is just for singletons! They don’t have anything for twins and I was like, “Oh, it might be kind of cool to be able to compare and contrast!” But no.
Some of the things I like the best… I think one of the initial screens that you go to actually has a really cool image of a baby in utero. And it says at the top, you can put in your baby’s name, but it automatically tells you what week you are. So someone’s like, “Hey! You know you’re pregnant. How many weeks are you?” I don’t know if you guys have a hard time figuring out.
Annie Laird: Oh, I always forget. I have to look at the apps.
Sunny Gault: Well look at the app, right?
Annie Laird: … Like what Thursday is it? I know it changes on Thursday.
Sunny Gault: (Laughing) Right? Exactly. It’s hard to remember all that, right? So it tells you the week at the top. And then you can click on these little areas to learn more about what the baby is doing. And there are some other cool features on it too. And in the tools section, they have some cool stuff. You can track your weight if that’s important to you; a kick counter, which I never did – my doctors wanted me to kick count and I never did; contraction time – I’m in a little bit different group because I’m a C-section girl, but I did use it with my first pregnancy, which was a vaginal birth. Those are some of the things that I really liked, but I wanted to talk to you ladies, who have had a chance to test this out, and see what you guys thought. So, Abby, I know you had a chance to look at it. What do you think?
Abby Finch: Yeah, I really poked around and tried out the different areas. And I also have something to compare it to, because I used two different apps. I used them during my first pregnancy and again this time, so I have something to compare it to. Overall I feel like it’s a little bit more comprehensive than the other two apps with all the things that it offers. For example, like you were saying, among the tools, the kick counter and the contraction timer. I actually had to get those as separate apps, because they weren’t in the pregnancy apps I was using before. So I did use a kind of kick counter and I found that it was really helpful. I didn’t end up using the contraction timer because my water broke. (Laughs)
And then one other thing I liked out of the tools in the Sprout application is the organizer. There’s like a doctor visit planner.
Sunny Gault: Yeah, I liked that too.
Abby Finch: And I was like, “Well I just keep my own notes”, but they have question ideas, which was really good. Like, “Oh, here’s an idea of questions I should ask during trimester two.”
Sunny Gault: Yeah.
Abby Finch: And so I liked it. And there was kind of like a little packing list. They have one quibble on the packing list that knows… like… things that you need. And newborn essentials – they had formula. So that might be one little piece of feedback to give them, an absolute essential you don’t need to buy is a formula, because… I didn’t know, it was my first pregnancy, I’d think like, “Oh, I’m supposed to have some.”
Sunny Gault: Yeah. And one thing I thought I could do too is allow those to be edited – like you can add to it, but I don’t think you can delete. Kristy, what do you think?
Kristy Iris: I actually have been doing kick counting. And I have a little piece of paper that my childbirth class gave us to do. And I never write it down. And quite frankly, I’m trying to… when I’m starting to go to sleep at night… trying to watch the clock and then I fall asleep. If I have the app… I really like that part of the app that will just start counting and I just hit the Kick. So that I think it’s actually… to me it would be worthwhile to upgrade this… I think it’s $3.99.
Abby Finch: Just for the counter, yes.
Sunny Gault: Ok. So for the ladies that were able to check this app out, the Sprout app, thumbs up thumbs down. Would you recommend it to another pregnant mommy?
Sunny Gault: Ok. We’re going to give this a Preggie Pals thumbs up.
Sunny Gault: Well you thought 40 was considered over the hill, but when it comes to pregnancy they have actually lowered the bar to 35. It’s called advanced maternal age and here to tell us all about it is Dr. Sean Daneshmand, Perinatologist with the San Diego Perinatal Center and founder of Miracle Babies, an organization providing information and financial support to newborns in the NICU. So Dr. D, welcome back to Preggie Pals!
Sean Daneshmand: Thank you so much, Sunny. Thanks for having me.
Sunny Gault: Yeah. Last time we had you here we were talking about high risk pregnancies.
Sean Daneshmand: Right.
Sunny Gault: Yeah. So I feel like this kind of is lumped into that category a little bit, or at least can be. So let’s define what advanced maternal age is. What does that mean?
Sean Daneshmand: Advanced maternal age is a term that is actually being phased out, because in the past we used to offer genetic screening and testing to women 35 and older, because they had a higher threshold for having babies with chromosome abnormalities. And since now these tests are offered to every pregnant woman, we’re really phasing away, phasing out the term “advanced maternal age”. However, 35 and older, women have an increased risk with their pregnancies, mainly chromosome abnormalities. And I can tell you more about that. Should I?
Sunny Gault: Yeah, let’s go ahead. Let’s talk about that.
Sean Daneshmand: So patients that have turned really 32 and above… their chance of getting pregnant – meaning the time fecundability, which is the probability of getting pregnant within one menstrual cycle, is decreased. SO it takes longer for women to get pregnant. 35 and above, when they get pregnant they have a higher chance of having miscarriages, unfortunately. When they do get pregnant they have a higher risk of having ectopic pregnancies. Also, multiple gestations are higher with women 35 and older. Once they are pregnant, obviously chromosome abnormalities; obviously… you know, every pregnant woman – especially 35 and older, because I see a lot of patients that are in that age category – they’re concerned about chromosomes, they’re concerned about congenital abnormalities. And there’s some data in the literature suggesting maybe there’s a higher risk of heart defect. I don’t want to scare people on this panel… (Laughs) And obviously I tell all my patients… older women, 35 and older, they’re all young and they do fantastic, but there are some concerns and some precautions that we need to take. So, again, up until the age of 20 weeks of pregnancy everyone is concerned, “oh my god, how’s my baby, how are the chromosomes?” and then we’ll talk obviously about the genetic screening and tests that are available. And then after that, gestational diabetes mellitus is higher, hypertensive-related crises are higher. And also it’s intuitive, the older you are, the more likely you may have some comorbidity, such as being overweight, having hypertension or diabetes, so the number of visits to the hospital might be a little bit higher, you Caesarean section risk may be a little bit higher.
Sunny Gault: Yeah. Well, ladies, how do you feel about this term in general, about advanced maternal age? I kind of didn’t… and for some reason, I kind of said this in the intro, I thought that it was 40 and over. And I don’t know if that’s just a societal thing – that again, you’re over the hill when you’re 40 or whatever and… Kristy, you’re not over the hill, that’s not what I’m saying, sweetie.
Kristy Iris: Oh, no, I don’t feel it. (Laughs)
Sunny Gault: But you know, society says that once you reach 40, your life is half over, which is ridiculous. But we’re trained to think that. So I guess… has advanced maternal age, Dr. D, has that always been 35?
Sean Daneshmand: Yes.
Sunny Gault: It has always been, ok. So ladies, how do you feel about this?
Annie Laird: I think back of my mother and she tells the story of when our youngest brother was born and this was back… the early 80s I guess… and there wasn’t a plush hospital accommodation, all the pregnant women were kind of together in one room as they labored. And then when it was time for you to have the baby you went into the delivery room. So the nurses, in taking her and asking her what her age was, she said 33 and it was like dead silence in the room and… “there’s the old lady over there.” But I think nowadays like you were saying, Dr., women are starting their career later, they’re putting off having their family, so I think it’s more common for women to start their family in the mid-30s or even their early 40s. Before they’d start thinking about that… When she had me, even her having me at the age of 26 I think it was, that was like, “Oh, so you waited a little bit to have a family”, you know. And nowadays if you’re asking anybody in their mid-20s, they’re like “Well I’m still having fun, I’m still…you know” So it was different, I think, of just how we’re growing our families now.
Sean Daneshmand: That’s true. And it’s important, Annie, that - whether you’re 35, 36, or 41 - I think it’s just important on you live your life. So, you know, lifestyle measures: how you’re eating, how you’re exercising, not using tobacco, just… What we do to stay healthy and decrease inflammation. - that’s the key. But there are obviously some independent risks factors when you turn older. I mean you have no control over what your eggs are doing. You have a higher tendency to have trisomy, so three chromosomes, such as 21 or 16. Those things you have no control over. But we certainly have some control over our environmental risk factors.
Annie Laird: I think on the whole I’m healthier now than I was in my 20s. And so I definitely exercise more – I didn’t really exercise in my 20s – eat better, so on the whole I feel better. And I’d also like to point out: my doctor doesn’t call me “advanced maternal age”; their official term is “elderly”.
Sunny Gault: And in the computer is “elderly”.
Sean Daneshmand: That’s awful.
Sunny Gault: What the heck is up with that?
Sean Daneshmand: It’s in the literature. It’s unfortunate.
Amy Askin: Also the multigravida means it’s not your first; if you have elderly primigravid – meaning that’s your first – and then after that the “elderly” would just get to me every time.
Sunny Gault: That’s my official diagnosis on everything: elderly multigravida. “Ok, thank you.”
Sean Daneshmand: That is awful. That is absolutely awful.
Amy Askin: It is.
Sean Daneshmand: It’s embarrassing.
Annie Laird: Thank you for saying that. And in my personal experience I haven’t had any issues. Knock on wood. I’ve been very, very fortunate. I was pleasantly surprised with both pregnancies to get pregnant in the first month.
Sunny Gault: Nice.
Annie Laird: And so far I have to say it’s been kind of sailing… so I just kind of have to like laugh a lot… I’m elderly? So what is that going to mean? Are they going to treat me different? Am I going to have to do more tests? So it definitely raises questions.
Amy Askin: I had the exact same experience, so I’ve been very lucky. And you know, I was listening to Dr. D talk about how you would have more difficulty getting pregnant or any of these things. I mean my midwives were always telling me “Oh my gush, you’re how old?” They would see the “elderly multigravida” on my chart and they would say “Oh my gush, I thought you were like 25!” (Laughs) And I’d say “Well in my mind I am.” (Laughs) I know, that’s what I keep telling everybody. I don’t know what this elderly stuff is all about. Yeah, I was very healthy and I’ve been very blessed and agree with everybody. I think that if you’re healthy in your habits, when you’re trying to get pregnant it seems to go a little bit better. I’ve had three beautiful pregnancies and beautiful births and I think I’m just healthier in general in my 30s and approaching 40s.
Sean Daneshmand: I agree, Amy. I think it’s important also… when patients come in… I had a patient who was 45 years old coming in a spontaneous pregnancy… it’s important to just inform patients on what’s out there in the literature. But really, this is not real science. There is some data suggesting that you have a higher risk of having a placenta previa, there’s a higher risk of having a growth restricted baby, there’s a higher risk of having gestational diabetes. What measures can we take to make sure that you do well.
Kristy Iris: But when you say high risk, it’s still in the minority; the percentage of the likelihood of me having a baby with Down syndrome at 41 is still very small.
Sunny Gault: Yeah. How much does it go up? When we say we’ve got an increased risk… you mentioned age 32… so between age 31 and 32, or 34 to 35, are we talking about a huge increase? I mean, how is that number picked out?
Sean Daneshmand: So the age of 35, it’s about 1 in 360 chance of having a baby with Down syndrome. Women at the age of 40… it goes up do about 145, so significantly higher. But still the odds are that your baby is going to be normal. For example, when we say preeclampsia is higher, the risk of preeclampsia is in the average patient, the average patient population, is about 3-4%. And for someone who is 40 and above it is about 7-8%. So I tell my patients “Your risk is higher, it doesn’t mean you’re going to have it. So get a blood pressure monitor starting at 20 weeks and start checking your blood pressure on a daily basis. And these are the parameters that I want you to look at; if it’s above this make sure you call me. So early intervention, just knowledge, I think it’s power. Just knowing what things to look for and not necessarily that’s going to happen to you and this is “Oh my god, you’re 41, oh my god, you’re doomed.” No, you’re going to have a healthy, beautiful pregnancy. Before your pregnancy most importantly just control the environmental factors – eat very well, take your folic acid, and know that the folic acid that everyone is talking about is methylated folate, so methylfolate. Make sure you’re not smoking, you’re not drinking, and eating very healthy.
Kristy Iris: Another thing that I think is missing from the medical model is the aspect that even though we might, as elderly, mature mother to be…
Sunny Gault: Experienced.
Kristy Iris: Yes, experienced. Well, I’m not even experienced yet, this is my first. But as an older woman – and I can’t believe I’m saying that – I’ve had a lot of living. I’ve done so much and I don’t feel like I’m putting anything on hold or missing out on any life. And so from a spiritual, mental, emotional standing point I think I’m treating my body and my baby so much better than I would have in my 20s, because I’m ready for this. So there’s the balance where there’s the medical part – yes, of course, there are higher risks – but there’s the balance of what that means and I’m even just creating a more sane, serene environment in my body for the baby to grow in.
Sean Daneshmand: Kristy I really agree with you. I think because the most crucial time in a child’s development: brain. I mean the most important organ in our body is our brain. And the most crucial time in addressing a child’s brain is a year to five. So it is now until the age of 5. So I agree. When I see an 18 year old coming to my office who’s pregnant I spend a lot more time talking about what you do after delivery. So when I see someone who’s in their 30s or 40s coming in I know that these people are obviously more experienced and they know what it means to take care of a child. So those discussions are not held as much. So I agree with you, because really that stage it’s so crucial how you nurture this child, how you create a very nurturing environment for this child’s brain to develop. Because 90% of who we are is really established in that time. And then your neocortex – your thinking brain – obviously continues to grow.
Sunny Gault: Ok. So we actually have a question from one of our listeners on Facebook and Stephanie, why don’t you tell us what our listeners say.
Stephanie Saalfeld: Ok. Our question is from Nicki Holmes. She says, “What are the hidden risks of getting pregnant after 40?” And she says, “I know about Down and such, but what other dangers are there?”
Sean Daneshmand: Ok. So, Nicki, there’s risk factors for preeclampsia, which is a condition where blood pressure goes up. There’s an increased risk associated with developing gestational diabetes. Those are the main two concerns. Also Caesarean section rates are higher with women 40 and over. Also, stillbirths are higher when you look at the overall increased risks associated with stillbirths, it’s about 2-3 births per thousand in younger women and for 40 and above it goes up to 9 per thousand. So, again: not huge, but the numbers go up. So therefore more testing is involved. I tell my patients to get screened earlier for diabetes. They also get screened again at 24 to 28 weeks for gestational diabetes mellitus. Like I said before on this show, I ask them to get a blood pressure monitor and start checking their blood pressure from 20 weeks onward every day. And I tell them, if your blood pressure is over 140/90 either of those please contact your provider. Every month we get an ultrasound because there is also increased risk associated with growth restrictions. Again, this is all done just to… we want to identify if there is a problem earlier than not. And starting at 34 weeks we recommend undergoing non-stress tests, which is basically recording the baby’s heart rate for longer than the 15 seconds or 10 seconds that the physicians listen or midwives listen to. The baby’s heartbeat – and that’s done for 20 minutes – and then also looking at the amniotic fluid volume – and that’s done starting around 34 weeks, twice a week until delivery.
Amy Askin: I have to chime in, the non-stress test was something I keep telling you guys and so hands-off. That was the most wonderful experience of my entire pregnancy.
Sean Daneshmand: You got to rest.
Amy Askin: I would sit in a chair and read a book and no one could interrupt me. And it was lovely. So I have to recommend the non-stress test for we, mature mothers.
Sean Daneshmand: Yeah. The non-stresses have a very good negative predictive value, so we’re looking if there’s any evidence of hypoxia with our baby, sort of like oxygenation. And I have to tell you something - this is not a HIPAA violation because I’m not naming any names – if it wasn’t for the non-stress test done recently, two weeks ago, I would have lost a baby. I mean in all honesty. I mean something just very rare happened with this patient, where one of the vessels in the baby’s heart was closing and that baby could have passed away within a matter of days. It was a very rare thing to happen, so obviously we don’t do it for that, but…
Sunny Gault: You caught it.
Sean Daneshmand: Yeah.
Kristy Iris: But the likelihood of a woman over 40 having an absolutely normal pregnancy is more likely than her having a problem.
Sean Daneshmand: Absolutely.
Annie Laird: I think that’s a great point.
Sean Daneshmand: And we have to always focus on that and I always tell that to patients. These are things that we talk about, we’re concerned about, but at the same time, your odds are you’re going to have a very healthy pregnancy.
Sunny Gault: Ok. So we talked about this really quickly earlier, or at least we kind of teased it. And there are different tests that are associated with advanced maternal age, things that may be recommended. And we’re going to talk about that. We’re going to take a quick break. When we come back we’ll talk more about those tests. We’ll be right back!
Sunny Gault: Alright. Welcome back! Today we are learning all about advanced maternal age, which is a term they give you once you become pregnant after age 35. And our expert is Dr. Sean Daneshmand, Perinatologist with the San Diego Perinatal Center and founder of Miracle Babies.
So before we dive back into this conversation, one thing that I should let all of our listeners know is something new we’re doing here on Preggie Pals: we want you guys to be part of our conversation. So like our Facebook page – we’re going to be posting updates on our Facebook page – as well as follow us on Twitter - so it’s just Preggie_Pals is our name - or you could go on our website, just click on the Twitter link. And basically we’re going to have a little Twitter party. So every time we record a show our fabulous producer Stephanie over here is going to be tweeting out some of the topics we’re talking about, asking you guys questions, you guys can participate in our conversation and ask Dr. D questions, for example in this episode about advanced maternal age. And yes, that’s one way you can get involved with our show. All you have to do, if you are following us on Twitter, look for the hashtag #preggiepalsvp, which stands for virtual panelists. Ok, let’s dive back into this. So, Dr. D, let’s talk about the first-trimester screening test and what is involved. Now this isn’t something that’s just for advanced maternity age. This is an optional test that any woman can partake. Is it recommended more for women of advanced maternal age to determine if there’s chromosomal abnormality?
Sunny Gault: Yeah. I think it’s recommended for patients that… When I see patients in the first trimester I ask them - there’s obviously screening tests that are available, they have 5% false positive results with these and… - what would you do with the information? And if a patient says “I want to have all the information possible”, then we go through the steps. So the first trimester screening involves two parts – one is a blood test and the other one is an ultrasound – which combines that data and basically gives you odds risk on Down syndrome and trisomy 18.
So remember, you guys and listeners out there, that inside this beautiful sack where the baby resides… how does the fluid get in there? It comes through fetal urination and baby’s lung secretion, baby spits inside. And how does it get out? It gets out through three ways – through the membrane, called the intramembranous pathway, the baby swallows it and it goes through the placenta. So 1% of these hormones go through the placenta and get into the maternal blood. So the first trimester, between 11 to about 13 weeks and 6 days, we do a blood draw for PAPP-A, which is Pregnancy-associated plasma protein A, and hCG. And then we look behind our baby’s neck, between the skin and the soft tissue, and we measure that distance. We take baby’s size, mom’s age, that blood work and that gives us an odds risk. “Ok, your risk for Down syndrome is 1 in 500 or 1 in 1000.”
Then between 15 to 20 weeks there’s another blood test called the quad screening test. And that involves a blood draw. It does not include an ultrasound; a blood draw, which screens for alpha-fetoprotein, human chorionic gonadotropin, Inhibin and Estriol. And these test results can combine with your first trimester result and give you the final risk assessment. So someone will say, “my risk was 1 in 1000 for having a baby with Down syndrome.” Let’s say the risk comes back positive. “My risk was 1 in 15”, for example. “Oh my god, oh my god, does my baby have Down syndrome?”
Also mom gets an ultrasound anywhere between 18 to 20 weeks. Sometimes moms may decide to get an ultrasound a little bit earlier. And then we look for soft markers – is there anything on this ultrasound? How does the baby look from head to toe? Then are there any signs of baby may have an increased risk of having Down syndrome? And then we try to combine those results with our risk assessment. For example, is there a bright spot on the heart? Is there fluid in the kidneys? Does anything look abnormal inside the baby’s brain, such as choroid plexus cyst, that increases the risk for trisomy 18? And the we try to combine those results with the blood test and inform women.
So, first trimester screening, second trimester screening, and now there’s something which in the past – a year and a half – we’ve been offering patients, which is the blood draw for fetal DNA. There’s a fetal DNA in the maternal blood. That screens for the most common abnormalities, which are the trisomies and the sex chromosomes abnormalities – the Down syndrome, trisomy 18, trisomy 13. And I’m sure everyone knows what those are – there are three chromosomes instead of two chromosomes, instead of two number 21s we have three for Down syndrome, three for number 18 and three for number 13. And that test is wonderful for patients who screen positive, who are at high risk, and it’s got an excellent sensitivity and specificity.
Now if a patient comes in and, god forbid, has for example a heart defect, which unfortunately affects 34000 babies here in the US annually, then… since there are other chromosomes abnormalities associated with that, then we offer amniocentesis. Or if a patient comes in and says, “I had a baby with trisomy 21 with Down syndrome with my previous pregnancy. What can I do?” The can go ahead and do this screening test or just proceed with the CVS, which is Chorionic Villus Sampling, which is done in the first trimester, usually past 10 weeks. And that is a catheter that goes through the cervix or trans-abdominally, through the abdomen, and gets some placental tissue and we check for fetal DNA.
Sunny Gault: And it has to be done at a specific time, right?
Sean Daneshmand: Yes. That’s done usually around 12 weeks; 12 to 13 weeks. And then between 15 to 20 weeks or between 15 to really 22 weeks you can do an amniocentesis.
Sunny Gault: Ok. Now can you talk a little bit about… both of those are considered invasive procedures, right? So what is the risk of something happening to the baby and with that risk what could happen?
Sean Daneshmand: So the biggest obviously risk factor is pregnancy loss. With twins, Sunny, it’s higher, it’s about 2.5% with an amnio. There may be a high risk with CVS and there may be a need for an amnio with the CVS. With an amniocentesis the risk is about 1 in 500 to lose a pregnancy. So one in 500 women that have amniocentesis may lose their pregnancy. And with CVS it’s probably 1 in 300.
More amnios are done now than CVSs, especially because these screening tests and diagnostic tests that are coming out. And, again, CVS is in the first trimester, a catheter that goes through the cervix and takes basically placental tissue, done under ultrasound guidance, so there’s a sonographer who’s standing there and scanning your baby and you can see this catheter actually going in and taking this placental tissue. And with an amniocentesis, again, it’s an ultrasound-guided needle – it’s a very thin needle, but it’s a long needle - that goes through the sack and draws fluid and basically within a week and a half we can have results. We can have results in the most common chromosome abnormalities. By doing something called FISH you can get results in three days on the most common ones, so Down syndrome, trisomy 18, trisomy 13.
Remember that most of these screening tests really are designed for Down syndrome. I mean they’re made to identify babies with Down syndrome because we’re not very good at diagnosing babies with Down syndrome on ultrasound. 50% of the time they look normal. So if we take 100 moms with babies with Down syndrome, we’ll miss 50 of those babies. We’ll say a baby looks normal. So really these tests are intended for patients that may say “I will not continue with this pregnancy” or “I really want to know the information.”
Sunny Gault: Ok. And obviously all these procedures are elective, right?
Sean Daneshmand: Absolutely.
Sunny Gault: Ok. Anything you do with your pregnancy is elective. No one can force you to take any of these.
Sean Daneshmand: Absolutely.
Sunny Gault: I have to share, with my personal experience I have more traditional medical care. I have an OB, I go through big medical provider, and immediately when they learned that I was 35 they assigned me to a genetic counselor – that was my first introduction to advanced maternal age – I was like “What do you mean? This is different. This is not like my other pregnancies.” I went in and I was really hesitant about this appointment, just because I just don’t think I wanted to be classified as advanced maternal age. I think I was having a personal issue with this. But it was really interesting because she was very knowledgeable and she was giving me all the information about the risks, about the procedures and really sharing more information about the percentages, like you were talking about earlier, Dr. D, as far as when you’re 35 it goes up by this percentage… And I found that really interesting. And it got pretty in depth. I think the appointment was about an hour and a half. And I learned a lot. And one of the things that I learned about and I wanted to get your feedback on this, Dr. D, is the non-invasive prenatal test, where they’re just drawing blood. These are done through third party companies. What can you tell us about that? Because I thought that was really interesting. I get really scared about invasive procedures. It all really depends on what you’re going to do with the information and everybody has a reason for doing it, but for me it’s a very scary thing. So this is more of a blood draw and it can gather similar information that an amnio or CVS would gather. Right?
Sean Daneshmand: Absolutely. The blood test looks for basically fetal DNA in maternal blood and it screens for the most common abnormalities – again, Down syndrome, trisomy 13, trisomy 18 and sex chromosomes abnormalities. And there are right now three competing companies that are doing this. Yes, I think it offers certainly a lot of information for patients that are high risk. So a woman comes in and says – remember, with twins 33 is considered advanced maternal age…
Sunny Gault: Oh my god! No one told me that yet! (Laughs)
Sean Daneshmand: So I have a lot of patients who come in and say, “You know what? I really want to avoid doing a CVS or an amniocentesis. What else do you have to offer?” It’s excellent also for really just information. And it can be done after 10 weeks and it can be done anytime during the pregnancy.
Kristy Iris: I had it done.
Sean Daneshmand: Yeah.
Sunny Gault: You did?
Kristy Iris: I did, because when we went for the ultrasound they tried to see the back of the baby’s neck to test for Down syndrome. Our little one is so active that they couldn’t catch the back of her neck, so they didn’t have that reading. So we decided to just go ahead. And the upside of it is that they also do the gender. So we were able to find out the gender early on as well.
Sunny Gault: So at what point, how many weeks were you? Do you remember when you did it?
Kristy Iris: 14 weeks? About that.
Sunny Gault: And the results came back pretty quickly, right?
Sean Daneshmand: Yeah. More than usually within a two week period.
Kristy Iris: Well it didn’t feel very quick.
Sunny Gault: In the grand scheme of things. But I know that you want that information, especially when you think something could be wrong. You want that information.
Kristy Iris: Yeah.
Sean Daneshmand: Sunny, I want to talk about what you said as far as meeting with a general counselor. I always tell patients “You know, this is information. Forget about all the terminology, the advanced maternal age. This is for information. The more informed you are, the better it is. So go in there and listen to these guys. They’re not pushing… it’s your decision ultimately. But there’s… every few months other new screening tests are available and it’s just for information. Do you want to be screened for cystic fibrosis? Do you want to be screened for spinal muscular atrophy? Do you want to be screened for fragile axe? So I think… the term “genetic counseling” is just… it scares people.
Sunny Gault: It’s scary. Yeah, it is.
Sean Daneshmand: But it’s information, you know. And the genetic counselor is wonderful; go there and just listen to them and you’ll decide with your partner what you want to do.
Sunny Gault: Yeah.
Abby Finch: Can I ask about that? When I first went in I said, “Well I’m going to be turning 35” and they didn’t offer the genetic counseling. And then I had my birthday last month and they said, “Do you want to go in and see a genetic counselor?” And I said, “Well in the second trimester what would they do?” So I didn’t go. Is there still a point? Or is it kind of after the fact now?
Sean Daneshmand: I think you can still meet with them, but certainly once you have passed a certain stage, especially with chromosomes, you can still… Can you do an amniocenteses at 22 weeks? Yes, you can, but there are obviously other risks associated with it, such as rupturing your membranes. Could you do a maternity at 21 or a harmony test? Yes, you can, so you can get more information that way as well. But it’s at time of delivery what’s your age – that’s when you’re considered advanced maternal age or not.
Sunny Gault: Oh, Well that’s really good information to know.
Amy Askin: That was information that was new to me, because I always think when I got pregnant was the factor, and so we were talking earlier about the increased incidents of Down syndrome and they show you… the genetic counselors show you the chart and everything. And so I was 38 turning 39, within a month of my due date. And so they said “No, we have to look at 39, not 38.” And I said “Well that kind of stinks.” (Laughs) I was like “Well I got pregnant then. Doesn’t that mean something?” “No.” “Well so maybe I’ll have the baby early then.”
Annie Laird: And Sunny you and I were talking about this I think at the last taping. As well as the fact that I had a baby at the age of 34 just last year.
Sunny Gault: Yeah. Exactly.
Annie Laird: So I’m like “Wait a second”. And so here I am, under midwifery care because I was very low risk. I had to have a very healthy baby and she’s about to turn one. And here I am pregnant again, I got pregnant when I was 34, so I had a baby at 34, got pregnant at 34, but now I’m having this baby at 35 and all of the sudden… what’s switched? You know?
Sunny Gault: I feel bad. I don’t know what to tell you.
Annie Laird: Exactly, yeah.
Amy Askin: It doesn’t sound like Dr. D does this, but it seems like everyone who was ever a caregiver of mine during those two pregnancies definitely made a big deal about it. Every sonographer, every nurse, every midwife, everybody. And that… I don’t know… I don’t want to say offended me, but it was very… I was such a healthy person, who’s never had anything wrong. And as a very active, healthy mother I just don’t understand the hang-up, but…
Abby Finch: A friend of mine was… maybe 39… and her point of view was that she liked it. Because she liked getting extra information and extra ultrasounds, so… she liked it.
Sunny Gault: I think that’s a good perspective to have, really. It’s like Dr. D said, it’s additional information. Forget about the definitions.
Sean Daneshmand: Yeah, I think everything is… you have to individualize it to every person. Like for example Annie had a healthy pregnancy at 34 and odds are she’s going to do exactly the same thing this time. So that’s what I tell patients. I think we need to treat patients, people, as human beings and we have to be respectful, so some of the terms, I agree, are…
Annie Laird: Elderly? Really? Can we petition to change that?
Sunny Gault: Yes! Can we? Preggie Pals will start a petition, that’s what we’re going to do. Dr. D, you tell me where to send this petition.
Sean Daneshmand: Yes. I’ll join, I’ll join.
Sunny Gault: It will be online. I’ll get moms around the world to sign this, I guarantee.
Sean Daneshmand: I love that.
Sunny Gault: Alright, Dr. D, thanks for joining us today. For more information about our expert as well as our panelists today visit the episode page on our website. And this conversation continues for members of our Preggie Pals Club after the show. We are talking about the advanced maternal age ultrasound - what is it and is it really needed? To join our club visit our website PreggiePals.com.
[Featured Segments: From Our Listeners. Thanks for the Cesarean Episode!]
Sunny Gault: Here is a comment from one of our listeners. This comes from Debbie Hanson. And Debbie writes on our Facebook page:
“I wanted to thank you for your recent episode on healing from an unwanted Cesarean. With my daughter I planned to have an un-medicated water birth and instead I had an induction, Pitocin, epidural, and Cesarean. After my daughter’s birth I had tremendous guilt and regret over how her delivery went. And even now, 14 month later, I still cannot fully move on and let go of those feelings. The quote from Pam, England, that your guest read, had a profound effect on me. I had carried a lot of guilt feeling that I had known better, but now I realize that I truly did do the absolute best I could have given the circumstances and who I was in that moment. Thank you for not only doing this show, but also for doing it now as we have just found out that we are pregnant with our second. I now feel much more confident in my ability to plan for an experienced birth for a second time.”
Debbie, thank you so much for sending this email and I’m so glad this episode helped you.
If you have a topic that you want us to explore on Preggie Pals you can either send us an email, contact us on Facebook, or also call our voice mail, which is 6198664775.
Sunny Gault: So that wraps up our show for today. We appreciate you listening to Preggie Pals. Don’t forget to check out our sister show Parent Savers, for parents with newborns, infants and toddlers, and our show The Boob Group for moms who breastfeed their babies. Next week we’re talking with the March of Dimes about how to reduce premature births. This is Preggie Pals – your pregnancy, your way.
This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.
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