StorkNet interview with
Laura Goetzl, MD, MPH
Author of
Healthy Pregnancy Over 35
Expert advice for every stage, from planning a baby to giving birth

Healthy Pregnancy Over 35HEALTHY PREGNANCY OVER 35

From eating the best foods at the correct times to adapting a working and social life, Healthy Pregnancy Over 35 is a practical guide to minimizing risks and ensuring an active, enjoyable pregnancy. Including step-by-step stress-reduction and exercise plans, lists of super foods and supplements, and sex tips, this book is packed with essential advice for mothers to be.

Read our book review here

About the Authors:
LAURA GOETZL MD MPH is a specialist in high risk pregnancy who practices and teaches at the Medical University of South Carolina in Charleston, South Carolina. She is board certified in Obstetrics & Gynecology and Maternal Fetal Medicine, and is a member of the American College of Obstetrics & Gynecology, the Society for Maternal Fetal Medicine, and the American Institute of Ultrasound in Medicine. She lectures regularly throughout the US. Dr. Goetzl balances her career with the demands of her husband's practice in surgical oncology. Together they care for their two small children, Gabriela and Lucas.
REGINE HARFORD BS, MS PhD is a medical writer with special interest in women's health. She is a member of the American Medical Writers Association and covers international medical conferences for the pharmaceutical industry, helps medical professionals with their publications and presentations, and brings up-to-date, relevant information to consumers. Giving birth to her youngest child at 39 provided her with first hand experience of the joys and challenges of mature motherhood. Regine is based near Atlanta, Georgia.

Healthy Pregnancy Over 35Healthy Pregnancy Over 35
by Laura Goetzl, MD, MPH and Regine Harford
published by Dorling Kindersley, 2005

To Purchase:
 • Amazon U.S.
 • Amazon UK
 • Amazon Canada

Today, women are getting pregnant and having children later in life than ever before. Healthy Pregnancy Over 35 by Laura Goetzl, MD, MPH and Regine Harford addresses the unique concerns of women over the age of 35 and provides expert advice for every stage, from assessing one's preconception health to adjusting to motherhood. StorkNet was very pleased to welcome Dr. Goetzl as our guest. She answered several visitor questions. Those questions and her answers follow. Read our book review here.

From Ellie: I am 35 and my husband and I are considering having another child. We have four year old boy/girl/boy fraternal triplets that were conceived spontaneously. Neither of us has a history of multiples in our families, so becoming pregnant with them was a complete surprise. I have asked several OBs, including my maternal-fetal medical team from the triplet pregnancy, about our chances of conceiving multiples again, but no one has had any statistics at hand. Have you seen any studies done on this? Is my risk of conceiving multiples again unduly high considering my history of one sponataneous multiple pregnancy and my age?

Dear Ellie: Certainly your chance of a multiple pregnancy is higher since you have demonstrated the ability to ovulate more than one egg per cycle in the past. Pinning down your exact chances of a subsequent multiple birth is difficult as your history and your age both increase your risk. The risk of repeat triplets is going to be low just because spontaneous triplets are so rare. However the risk of twins, while small, is there, but likely less than 10%.

From Christina: I'm 40 and pregnant for the first time with the assistance of IVF and donor egg. My quad screen came back positive 1:142. Is this screening accurate when a 25 year old's egg is used.

Dear Christina: It is accurate if the age they put on the lab test slip was 25. The age of the donor is the starting risk for Down syndrome. Then the chemicals in your blood either increase or decrease that risk.

From Jennie: I am 37 years old and am considering pregnancy. My concern besides age is about how alcohol consumption over the years may manifest on my health and subsequently a developing fetus. Unfortunately, weekly tailgate parties and many loooong Mondays for many years is fairly accurate. This worries me more than anything else. I'm not sure how long to abstain before attempting pregnancy (3-4 months???). I would NEVER consume after conception.

Dear Jennie: In general, the risks are minimal from past alcohol use unless you drank enough to seriously damage your liver. If you have alcoholic cirrhosis, this will increase your risk of pregnancy complications. Alcohol itself doesn't stay in the body long, so if you abstain while you are trying to conceive you should be fine. However chronic heavy alcohol use can deplete your body of important nutrients, especially B vitamins. Therefore, I would recommend that you take a daily prenatal vitamin for at least 3 months before attempting conception. Taking prenatal vitamins prior to conception will decrease your chances of having a baby with a malformation.

From Karen: I had my first daughter when I was 28 and my second at 31. I had pre-term labor with my first at 31 weeks, probably due to a bad UTI, responded well to terbutaline, and my daughter was born healthy just shy of 37 weeks. Had recurrent cramps with my second child from 26 weeks on, back on the terbutaline, and she was born at 37 weeks. Miscarried my third child at 12 weeks when I was 34, and testing showed the baby had Trisomy 13 and had died around 8 weeks, 4 days, although we had seen a good heartbeat at 6 weeks. I'm now 35 and pregnant again, will be 36 when I deliver. I am worried about another Trisomy, but am also worried about CVS and amnio due to my history of pre-term labor. Any advice?

Dear Karen: Given your age and your history of prior trisomy, a CVS or amnio is certainly reasonable. There is little to suggest that these procedures significantly increase the risk of preterm delivery. Another option, would be weekly shots of 17 hydroxy-progesterone, which will decrease your chance of preterm birth in this pregnancy. These shots are usually started in the second trimester, after CVS or amnio has already been performed.

From Monica: I am 36 years old and thinking of having a third child. My first pregnancy was uncomplicated and that child has just recently been diagnosed with high functioning autism. My second pregnancy was unplanned and she was born 14 months after. No complications. What are my chances of having a child with autism? What tests can be done?

Dear Monica: I have to say this is outside of my area of expertise. I would arrange to meet with a genetic counselor prior to conception, although it is my understanding that most cases of autism cannot be diagnosed prenatally.

From Tammy: I am 41 years old and 8 weeks pregnant after a successful IVF. What is the maternal-fetal medicine specialist's protocol for high risk pregnancies due to IVF and age?

Dear Tammy: In general we would treat your pregnancy much the same as any other. You do have an increased risk of several complications including: chromosomal abnormalities, high blood pressure, gestational diabetes, cesarean delivery and intrauterine fetal demise. You should see a genetic counselor early in the pregnancy to determine if you would like to be screened for chromosomal problems (first or second trimester tests available) or whether you would like to proceed directly to CVS or amnio. If you are average weight, I would perform routine screening for diabetes (sugar drink followed by blood test) at 24-26 weeks. Towards the end of pregnancy you will be seen weekly to check for signs of high blood pressure complications. Weekly fetal testing in older women is controversial and may lead to unnecessary interventions. Your chances of vaginal delivery are still good, but your risk of cesarean is a bit higher than if you were younger.

From Kim: I am 37 years old and am considering having a second child. My first child (a healthy girl) is now four years old. We conceived her easily with no pregnancy complications. I've been told that using oral contraceptives may add longevity to a woman's fertility. The theory being that if ovulation has been suppressed for years and the number of viable eggs is predetermined at birth, the number of fertile years may be extended. Is this true?

Dear Kim: This is not my area of expertise, but the studies I read suggest that this is controversial. However, in one large study of Danish women, oral contraceptive (OC) users had an average age of menopause of 51 1/2 compared to an average age of 50 in non OC users. In women who used OCs the most predictive factor was age when OCs were started, rather than current use. This means that if you used OCs when you were younger, you may have prolonged your fertility, but starting them when you are older for this purpose may not help.

From Becky: I'm 38 years old and 38 weeks pregnant with my first child. So far, I've had no dilation or ripening of any kind. My doctor says this is common when women have their first child over 35 and believes that I need to be induced. She doesn't seem to believe I'll start on my own. Have you heard of this?

Dear Becky: Women over the age of 35 are more likely to deliver by cesarean. However being induced, especially when your cervix is not favorable, is more likely to result in your having a cesarean than your age. In any event, uncomplicated pregnancies should never be induced before 39 weeks at the earliest. Unless your doctor is concerned about your baby's well-being, it is probably safest for you to wait until 39 to 40 weeks before considering induction.

From Jennifer: I'll be turning 35 in a couple of months and have been on birth control pills on and off for a number of years. After age 30 my periods became heavier and a little more painful so I went back on them about 18 months ago. My new husband and I are talking about starting a family and I was wondering how long does it take for the pills to get out of your system? Can taking the Pill on and off for a number of years have any negatives implications for a healthy pregnancy?

Dear Jennifer: A history of birth control pill use should not increase your risk of pregnancy complications, however the heavy bleeding could be a sign of fibroids which have been associated with problems. Were you ever given a diagnosis for why your bleeding became heavier? I wouldn't worry about getting the pills out of your system as they will not harm your baby. The main complication of getting pregnant before you have a period off the pills is not being sure of your exact dates. However early ultrasound is very helpful in clearing up how far along you are, so I wouldn't wait on account of OC pill use. However, if you are not pregnant yet, I would get evaluated for your heavy bleeding prior to attempting pregnancy.

From Hildysue: I am 44 1/2 years old and would like to become pregnant. I already have four healthy girls. I got pregnant immediately with each baby. I decided to buy a fertility monitor to see if I would get an LH surge. The kit worked and I got an LH surge on Day 11 which means high fertility. I continued to test and I got peak fertility a couple days later. My question is how accurate are these fertililty monitors in women my age? My doctor told me that I should go to a reproductive endocrinologist and do blood work and get an ultrasound to see the conditions of my ovaries, etc. Are all those tests necessary, since I got the LH surge with the monitor?

Dear Hildysue: I would have to agree with your doctor that you should be evaluated by a reproductive endocrinologist. The baseline tests are not very expensive, and you don't want to waste a year trying to get pregnant and later find out you needed help as time is of the essence.

From Karen: I am 38 and 15 weeks pregnant. I had the first trimester screening which came back with an increased risk of Downs (1 in 92). I am considering having an amnio, but I am on Lovenox during pregnancy for homozygous Factor V Leiden. Is there a standard protocol for patients on blood thinners who have an amnio? I am concerned about bleeding from the procedure if I take the Lovenox, and of clotting if I don't, and just overall increased risk to the fetus.

Dear Karen: Usually it's best to hold your Lovenox for 24 hours before the amniocentesis, and then restart it 4 to 8 hours afterwards. Your risk of getting a blood clot in that short window are low, and this will reduce the risk of bleeding complications with the amniocentesis.

From Elizabeth: I am 37 years old and about to give birth to my first baby. My pregnancy has been a healthy one except for gestational diabetes -- although I am not overweight and had no other risk factors except for age. My question is, we would like to have a second baby soon, before I turn 40. How long do you suggest waiting before trying to conceive again?

Dear Elizabeth: In terms of reduced risks of pregnancy complications, an inter-delivery interval of at least 18 months is recommended. That would mean waiting until your first baby is about 8 to 9 months old until trying to conceive again. If you were able to become pregnant easily without treatments, this is reasonable. If you had difficulty conceiving, you may choose to attempt pregnancy sooner. See how you feel, being pregnant with an infant that young is pretty exhausting.

From Kara: I just turned 34 years old and I am thinking about having a second child. My husband and I conceived our first child easily, but I developed kidney issues in the last trimester, my water broke early and I ended up with eclampsia (no signs of high blood pressure until my seizure). Our daughter was delivered after the seizure at 37.5 weeks. My husband would like to wait another year or two to get pregnant. I am concerned that I could develop eclampsia again, especially if we wait to get pregnant when I am over 35. Does maternal age increase the risk of eclampsia reoccuring in another pregnancy?

Dear Kara: Having eclampsia is certainly scary. Since you developed eclampsia at full term, the chance of recurrence in a subsequent pregnancy is low, about 2%. The risk of a milder form of preeclampsia is about 25%. While maternal age is a risk factor for preeclampsia, I don’t think another additional year or two will substantially increase your risk. On the other hand, waiting will not decrease your risks, if this is why your husband wants to wait. Good luck!

From Christi: I'm 43 years old, this is my 5th pregnancy (two healthy births). One of my two miscarriages was tested and was found to have Down Syndrome. What are my chances of another Down Syndrome baby? I'm interested in numbers. I also plan to have CVS as soon as possible.

Dear Christi: Based on your age, your risk of Down syndrome in a subsequent pregnancy is about 1 in 50 (2%) and of any chromosomal abnormality is about 1 in 32 (3%). Some genetic counselors would add an additional 1% risk (ie 3% for DS and 4% for any abnormality) because of your previous case of Downs.

From Vicki: I am 38 years old and pregnant with my second child. My first pregnancy was over 8 years ago, gave birth to a healthy baby girl. Today I received a call from my doctor that my triple screening test shows an elevated risk (1/50) for a baby with Down syndrome. I'm already scheduled for a Level II ultrasound next week but wanted to know the probability that a Level II could detect a problem if there was one. I would like to avoid the amnio if possible but would also like the reassurance that all is well. I understand that the amnio is diagnostic and 99% accurate and that the ultrasound is not, but I was wondering about the level of accuracy for this particular abnormality and what should they be looking for?

Dear Vicki: Ultrasound is an imprecise test for the detection of babies with Downs because some babies with Downs syndrome will have a totally normal ultrasound. However a normal ultrasound does make Downs less likely. If you had a high quality ultrasound that was normal, our genetic counselors would quote you a new risk of 1 in 1/139.

From Bonnie: I am going to be 38 next month and I am weaning off of Paxil because I want to have a baby. Do you know how long I should wait after my last dose to try to conceive? And also are there supplements I could be taking to benefit a pregnancy at this age?

Dear Bonnie: Every woman who is trying to become pregnant should be taking prenatal vitamins. I may also be helpful to take extra folate (1 mg per day). Regarding your Paxil, the half life is about 21 hours – so most of the drug should be out of your system after 1-2 weeks.

From Dixie: I'm almost 44, healthy and fit, no children, and within the past year I've had 2 miscarriages. The first was at 8 weeks after seeing a strong heartbeat (although I was spotting); the second at 8 weeks after the doctor detected the pregnancy was not viable. I've been trying to get pregnant for the past 4 months and am getting worried. I know I'm racing against the clock. Do you suggest I see a reproductive endocrinologist?

Dear Dixie: Absolutely!

From Weazie: I am 38 and my husband (43) and I would like to have 1 more baby; we have 3 healthy children already. But we are worried about twins because he is a fraternal twin. Should we be worried?

Dear Weazie: The chance of twins definitely increases with age. Your risk of having spontaneous twins at age 38 is about 14 per 1000 (1.4%). Your risk may be slightly higher with a family history. If you take medication such as clomid to get pregnant, the risk is much higher.

From Amanda: I'm 39 years old, 40 on my due date. I have just had an amnio at 16 weeks which was easy, no cramping or pains. I am writing with regard to fibroids - I was diagnosed with having a submucosal intracavitary 1.8 x 1.2 x 1.2, but since becoming pregnant have now multiple fibroids, one of which is quite large. I am very concerned about late miscarriage with these - maybe distorting my uterus. So far I've had a very easy, painless pregnancy. Any advice on what are the danger signs and chances of going to term?

Dear Amanda: While a small submuscosal fibroid may possibly increase the chances of infertility or early miscarriage – you are beyond that point. Most of your fibroids sound relatively small. If your larger fibroid is not distorting the cavity of your uterus, the chances of preterm birth or other complications are low. Usually you will not have an increased risk unless your fibroid starts to degenerate, causing pain and inflammation, which may stir up preterm contractions. If you are pain free you are in good shape! Your doctor may keep on eye your fibroids by ultrasound intermittently during your pregnancy to see if they are growing.

From Sheri: I am 40 and considering trying to get pregnant again. I have a wonderful 5 1/2 year old son. I had severe post-partum depression after his birth that was finally controlled with Prozac. My doctor has assured me that I can stay on Prozac during the pregnancy without harm to the developing baby. What are your thoughts on this?

Dear Sheri – There are clearly some concerns regarding use of serotonin uptake inhibitors during pregnancy. There is a slight association between the use of these medications as a group and low birth weight and preterm birth. However, the strongest predictor of whether or not you will have a preterm birth is whether or not you delivered early in your previous pregnancy. If not, I would be less concerned about this possibility. The evidence that these medications causes birth defects has been inconclusive, although there is some evidence that using paroxetine (Paxil) may be more likely than other agents to increase the risk. Most studies agree that use of serotonin uptake inhibitors in the third trimester of pregnancy is associated with a fetal withdrawal syndrome which may cause irritability and some feeding issues. However, experts agree that when women need to be treated for depression, the risk of neonatal withdrawal is outweighed by the risk of untreated depression. Therefore, the most significant question is – do you need Prozac during the pregnancy or just post-partum? This is an important question that can only be decided between you and your physician. If you need treatment, I would take your Prozac.

From Cynthia: I am 47 and would like to get pregnant. My husband is now 50; he had a vasectomy for 17 years and was "joined" 2 years ago. His latest sperm count reveals 70% is active. I had four other children by my first marriage but those were in my younger years. I understand the risks are very very high. I felt I had a miscarriage 1 1/2 years ago. I consulted my doctor a year ago and he subjected me to a test and confirmed that I am still healthy and can conceive. Is it possible for us to have a child?

Dear Cynthia – While it is more difficult for women at 47 to become pregnant, whether or not you will be able to become pregnant is based on your individual reproductive health. If you are still ovulating regularly, it is possible. If you have not become pregnant, and have been trying for 6 months you should see a reproductive endocrinologist for some baseline tests. If you do become pregnant, there is still an increased risk of miscarriage, usually from chromosomal abnormalities. Therefore, while not impossible, I expect that you may have some difficulties in becoming pregnant. One option is to consider egg donation, a choice that will increase your chances of pregnancy and decrease your risk of chromosomal abnormalities, since that risk will be based on the age (usually young) of the egg donor. Good luck--I wish you well with your efforts!

From Janet: I am 55 years old and I am wanting to carry my grandchild for my daughter-in-law and stepson. Is it possible that I can give birth to a healthy baby for them? I still have very normal periods, and I am in great shape.

Dear Janet: This is possible, but not optimal. I would get a full physical, including stress testing for your heart, prior to considering this. Talk to your primary care physician about your intentions and listen to his or her advice and opinions. However, unless your daughter-in-law has a VERY serious medical condition or does not have a uterus, it might be better for her to carry a pregnancy herself.

From Beth: I am 37 years old and just had my first pregnancy end in miscarriage at 9 1/2 weeks. I had a D & C and now am waiting for my next cycle so we can try again. According to my doctor, I may have a 'not perfectly shaped' uterus. I most likely will have the dye/ultrasound test done to find out the shape and flow of my reproductive organs. After that information we plan on trying again to conceive. What are my odds of miscarrying again and if I do, should I then seek help with a fertility specialist? I don't want to 'waste' any more time with disappointments.

Dear Beth: Don’t panic after one miscarriage. Miscarriage is so common, that this is entirely normal. However, if you have a second miscarriage (while still most likely normal) it would be reasonable to seek a consultation with a reproductive endocrinologist.

From Marie: I just turned 40 and confirmed my pregnancy this morning. I delivered a healthy baby 18 months ago; however it was a complicated pregnancy due to fibroid tumors. Is there any information that you can give me on pregnancy and fibroid tumors. I know that my age increases the risk of miscarriage but will the fibroids add to the risk?

Dear Marie: Whether or not fibroids increase the risk of miscarriage depends on their size and location. If the fibroids are not affecting the inside lining/shape of the uterus, then it is unlikely that they will increase your risk of miscarriage. Large fibroids that distort the uterus can increase your risk of preterm labor and possible cesarean delivery -- both because of their size, and because they are more likely to act up during pregnancy – resulting in pain and inflammation. It is important to avoid taking non-steroidal anti-inflammatories like motrin or anaprox (Naproxen) during pregnancy since they can harm your baby.

From Debi: I'm 39, my husband is 43 and I'm 13 weeks pregnant. This is our first pregnancy after trying to conceive for over 5 years and finally got pregnant on our third IUI attempt. I had the Nuchal Translucency screening done at 12 weeks and it came back with 1 in 14 odds of carrying with Down syndrome which seemed rather high especially since they said the scan itself showed a "normal" amount of fluid behind the neck. Can the ratio be so high because I'm overweight (210 at 5'7"), almost 40, and nephew on husband's side has Down syndrome? So far we've turned down the amniocentesis and will request a quad and Level II ultrasound instead (since we plan to keep our baby regardless of any chromosomal abnormalities anyway) but why is the ratio so high?

Dear Debi: First trimester screening combines several factors to determine your risk of a baby with Downs: your age, the nuchal translucency, and two chemicals in your blood: PAPP-A and free beta HCG. Although your age definitely contributes to your risk, your age based risk is 1 in 31. Therefore, if the nuchal translucency was normal, your blood values must have indicated an increased risk. Your weight and family history does not significantly affect the test. There is no point in performing the quad screen because you have already had a positive screening test. If you’ve already decided against an amniocentesis then the quad test is not needed. The ultrasound will be helpful. Although the ultrasound cannot rule out Down syndrome, it can detect heart defects associated with Down syndrome that might make it safer for you to deliver your baby at a hospital that can repair heart defects.

From Vivian: I am 40 years old and wish to become pregnant with my second child (first is 10 months old, very healthy - I had an easy pregnancy). I am worried because I am on Lamictal for a mood disorder, and also have high cholesterol (low BP though). Is it too much to risk, given those factors and my age?

Dear Vivian – Having high cholesterol will not make your pregnancy high risk – but you do need to stop taking medications to lower cholesterol prior to trying to become pregnant as they can be harmful in pregnancy. The risk of birth defects with Lamictal (used alone) is similar to that in the general population. However, it’s always best to use the lowest dose possible that still controls your mood. Based on these factors, your pregnancy is not particularly high risk.

From Mary: I am currently 12 weeks pregnant with a 'surprise' pregnancy. I'm 43, have 3 healthy girls with problem-free pregnancies, and vaginal births. I'm out of my mind, though, with worry over the baby having Down syndrome or other problems. I just took the early screening test (Ultrasound with blood test), and hope things look good. We've got no genetic issues on either sides of the family. Is there still a good chance that the baby will be OK? I'm sick to my stomach with worry.

Dear Mary: If the first trimester screening test is normal, then your risk is less than 1% that your baby will have Downs. However if you are out of your mind with worry – go ahead and have a CVS (chorionic villus sampling) now or an amniocentesis at 15 weeks. The risk of these tests is relatively small and it sounds like it will be worth it to you to have the peace of mind.

From Liz: I'm 44 and 11 weeks pregnant with my second child. I had my first at 41, and with the exception of first trimester morning sickness, had a normal pregnancy and healthy baby at delivery. I'd done the quad blood test before but have heard there's a new test that can be done in the first trimester involving a finger prick and ultrasound. Could you elaborate on this? Does it show Downs risk? What is my risk given my age? In my last pregnancy, I tested in a younger age group.

Dear Liz: First trimester screening for Down syndrome is similar to the quad test, but is done earlier. The first trimester test can be done between 11 and 13 6/7 weeks, while the quad test is done after 15 weeks. As you said, the first trimester test uses ultrasound and a blood sample, while the quad test uses only a blood sample. Both tests report your actual risk of Down syndrome in a “1 in x” format. Based on your age alone (if you are 44 at delivery) – your risk of having a baby with Down syndrome is 1 in 23. Both tests do a good job of detecting whether or not your baby has Downs, but the advantage of the first trimester test is that you receive the results earlier.

From Marina: I am pregnant with my first baby and will be 42 by the time he is delivered. I conceived in the very first month of trying and when my doctor ran the quad blood test, the Down syndrome risk was determined to be 1 in 500 - much better than expected for my age. This is causing me to consider that I might want to try to have a second child before I turn 45. Would the results from the quad test of this baby suggest that I would also have less risk than is normally associated with my age for a second pregnancy? Or is the test not so much about my body's condition and different for each baby?

Dear Marina: I’m glad you are having an uncomplicated pregnancy. If everything goes well, then the chances of having a second uncomplicated pregnancy are good. Unfortunately, the risk of Down syndrome will still be elevated in your second pregnancy – despite the good test result you had in this one. Your risk is related to the age of your eggs, not your physical good health. However, if you have another good test result – like this time – your risk can go back down.

From Debra: I had my first baby at 36 and developed HELLP Syndrome. My child was born (by emergency C-Section) 11 weeks early. What are the chances of developing HELLP again with a second pregnancy? I will be 40 in a couple of months and am not pregnant yet, but considering the option.

Dear Debra: If you developed HELLP syndrome in your last pregnancy at 29 weeks, you are at increased risk for some form of preeclampsia in your next pregnancy, although you may not get HELLP. Your risk depends on whether or not your have a reason that you developed HELLP. Some maternal fetal medicine specialists are testing for an increased tendency for blood clots (thrombophilias) in women with early onset HELLP in a prior pregnancy. You may want to consider a preconception consultation to discuss your recurrence risks and whether or not testing is indicated.

From Jen: Are breech babies more common in older moms. I'm 39 years old and 32 weeks pregnant with my fourth child who is currently breech. What are the odds that he will turn? Does maternal age make a difference in the odds?

Dear Jen: Maternal age is not a big risk factor for breech presentation. It is not uncommon for babies to still be breech at 32 weeks so I wouldn’t worry, because the majority of the time your baby will turn. If your baby doesn’t turn by 36 weeks and you have had prior vaginal deliveries, you can consider a procedure called a version that guides your baby into the head down position.

From Mara: My husband and I have been trying to get pregnant for 5 years; I am 39 going on 40, and we don't want to do IVF for just the fact it is only a 25% chance to conceive and the fact that it is very expensive. What can we do to try to do it on our own? I am taking the proper vitamins and eating well. What else can we do?

Dear Mara: IVF is expensive, but given that you have already been trying to get pregnant for five years without success I think it is your best chance. If you have not been doing so already, I would use some sort of ovulation prediction to time your intercourse. The cheapest course is using a basal body thermometer. A more expensive option is an ovulation prediction kit. In addition, if you can't afford IVF you may still want to consider seeing a reproductive endocrinologist to review your options and to make sure you have had a basic lab workup. One option may include oral medications to increase ovulation without full blown IVF.

From Debby: I am 44 years old and pregnant with my first child after 3 miscarriages and 3 IVF attempts. I am at the 16th week and praying. I am currently on several medications, including prometrium and lovenox injections. My doctor has just indicated that I will likely continue both of these medications throughout the entire pregnancy, which isn't a problem, but I am curious about the prometrium. Now that the placenta is producing progesterone, what is the continued benefit of added progesterone?

Dear Debby: If progesterone is being given because of recurrent miscarriage or "luteal phase insufficiency" then it is usually discontinued after 12-14 weeks. This is because, as you point out, the placenta usually produces sufficient progesterone to sustain the pregnancy after about 9-10 week's gestation. Progesterone is usually continued a week or two past that point for good measure. If you have risk factors for preterm birth, progesterone may be helpful, but should be given as a weekly shot.

From Teri: I am 35 years old and pregnant with my second. I had a quad blood test and my numbers came back on the Down's part as 260. Everything else came back normal. My doctor said that normal range was 270. He does not recommend amnio or anything else. I am 18 weeks. How serious is this and how do I enjoy the rest of the pregnancy with this looming over my head? Would a detailed ultrasound be of any help at this point?

Dear Teri: Your risk of having a baby with Downs is 1 in 260. How seriously you take this (and how it affects your enjoyment of your pregnancy) is personal. If you are still worrying, an amniocentesis may help ease your mind. A detailed ultrasound may slightly reduce your risk (if it is done at a level II center, is completely normal, and all the fetal anatomy can be seen) but can't rule out Downs. However your risk is already very small (< 1/2%). Is getting an ultrasound going to reassure you, or are you still going to worry? If you will continue to worry, then go ahead with amniocentesis.

From Kathryn: I am 36 and considering becoming pregnant with my fifth child soon. Most books address older mothers having their first babies. Are the risks the same for older moms with 4 previous, healthy pregnancies and no complications?

Dear Kathryn: In most cases, having had four prior healthy pregnancies is a good predictor that your current pregnancy will also be healthy. The only exception is your risk of Down syndrome. This continues to increase with age despite your history of healthy children.

From Michele: I am 36 and pregnant with my second child. I had an amniocentesis performed at 17 weeks. At what point can I consider myself "out of the woods" for a possible miscarriage due to the amnio? Can a miscarriage from the amnio occur weeks after the procedure?

Dear Michele: For practical purposes you are probably out of the woods 2-3 weeks after the procedure. Most miscarriages after amniocentesis are due to bleeding or infection that was initiated at the time of the procedure. If you haven't had any cramping, pain, leaking fluid or spotting and it's been a few weeks - I would let out that breath that you've been holding. You can have a late miscarriage, but it's more likely to be related to other conditions and less likely to be due to the amniocentesis.

From Debbie: I am 40 years old and have had 2 miscarriages, 1 in 2002 and the other in 2003. Both miscarriages were at 8 weeks. My Doctor can't find anything medically wrong. I have 2 boys ages 6 and 9.We are trying to get pregnant again. Should I seek other help? I don't have insurance and can't afford much. I'm scared that I will lose another baby. What can I do?

Dear Debbie: At 40, your chance of miscarriage is considerable even if there is nothing wrong with you, because most miscarriages are due to chromosomal problems (that increase with age). It's hard to weigh the expense of a workup for recurrent miscarriage (expensive) against the emotional stress of trying again and again. You may want to consider trying again one more time - then seeking the advice of a reproductive endocrinologist or high risk pregnancy doctor if you miscarry again. I also worry because you have two children already and can't afford health insurance . . . Everyone has personal reasons for why they desire more children but personally, I have chest pain wondering how I will pay for the children I already have!

From Elizzabeth: I had a gastric bypass and have lost 129 lbs so far. It's almost 8 months since the surgery, and I just found out that I am pregnant. I am 44 years old with a 15 and 6 year old. Does the surgery affect my chances of having a healthy baby? What are my chances?

Dear Elizzabeth The weight that you have lost from the surgery probably increases your chances of having a healthy pregnancy. As you lose weight, your chances of miscarriage, gestational diabetes and hypertension decrease. The main risk after gastric bypass is that you may not be getting all the nutrients you need. You should be taking extra iron and vitamins (ideally before you become pregnant). See your OB for recommendations.

From Tracy: I've had a miscarriage (7 weeks) and a Down syndrome pregnancy that my husband and I terminated at 19 weeks. Testing indicated that we have less than 1% chance of having another baby with Downs but my husband and I are 42. Do you have any data about women who have produced another baby with Down syndrome in situations like mine?

Dear Tracy: Both your age and your prior history are significant factors in your risk of recurrence. Recurrence is rare - but it can happen. What type of testing are you referring to? If your serum screen gave you a 1% risk for Downs this is better than your age based risk (1 in 64 for Downs, 1 in 40 for any chromosomal abnormality), but still screen positive (higher risk).

From Jenny: I am a 37 (almost 38) year old mother of a 2 year old and very much want to have another baby. I am afraid of having a Down Syndrome baby. I have read there may be a small chance of reducing your odds by consuming more folic acid. What is your take on this?

Dear Jenny: Some preliminary work has linked folic acid metabolism to risk of Down syndrome. However this remains controversial. What is certain is that taking 1mg of folic acid daily before you conceive reduces the chance that your baby will have spina bifida and also helps your body fight off anemia. Therefore it certainly can't hurt to take it! Good luck!

From Hilary: I am 37 and am about 8 weeks pregnant. In addition to everything else, I am worried about ectopic pregnancy, because I have an intermittent sharp pain on my lower right side. Does the risk increase with age?

Dear Hilary: If you are 8 weeks pregnant - an ultrasound should be able to determine for certain whether or not you have an ectopic pregnancy. Often women will experience some pain on their right or left side from the ovary where the egg that started the pregnancy came from. The biggest risk factors for ectopic pregnancy are going to be: having an IUD in place, smoking, prior tubal surgery, prior ectopic pregnancy, and history of pelvic inflammatory disease. The risk of ectopic pregnancy does increase somewhat with age, but the chances are still relatively low (only a few percent) at your age.

From Amanda: I've just turned 36, we have been trying for a baby for 4 months, and we are both fit and healthy. I was wondering what I could do to increase my conception chances and what chance of pregnancy do I have each month. Does this get better with each cycle?

Dear Amanda: If you know you are ovulating normally and/or have regular periods your chances of pregnancy each cycle approach 20%. Age is important as the rate of pregnancy with each cycle declines to about 5% by the time you reach your 40s. You should try to time your ovulation by some method (basal body temperature, cervical mucus, or ovulation predictor kit) so that you can plan intercourse on the best days. Although potentially less romantic, this kind of effort will boost your "per cycle" fertility rates. You chance of fertility with each cycle are about the same up to a point, but decrease if you haven't been able to achieve pregnancy after a year of trying as this may be a sign of a fertility problem. Your chances of infertility at your age are low (22%) - so chances are that everything will be fine and that you will become pregnant soon. I wouldn't even consider seeing a reproductive endocrinologist until you have been trying for at least 6 months. If you don't have regular cycles you should consider seeing a reproductive endocrinologist sooner. Good luck!

From Martha: I am 36 and am pregnant with my 5th child. I want to know how much exercise is healthy and if I can continue to run on the treadmill. I seem to feel like I am overheating at times. I want to exercise during my pregnancy because I have heard that it is harder to recover your prepregnancy weight the older you are when you give birth.

Dear Martha: Moderate exercise is safe in pregnancy. While pregnancy is not a good time to start a new rigorous exercise program - you should be able to continue your current exercise up to a point. Try not to get too overheated; make sure you take the time to warm up and cool down properly. Drink plenty of cool water while you are exercising. Try to maintain an intensity that allows you to continue speaking normally. This amount of exercise should keep you in good shape for birth and recovery!

From Elza: I had my first child at age 42.5 and am now expecting our 2nd which will be due after I turn 46. My weight went up about 12 pounds after baby 1 and I take Synthroid due to thyroidectomy - it was after the thyroid surgery that I found it difficult to lose weight. My first pregnancy went very well and I went the full 9 months to the day - labor 12 hours and a healthy 10.5 pound baby boy. I'm hoping that if I follow the same guidelines I did last time, I will have another healthy baby. Is there anything that I should be concerned with in order to have a healthy baby and pregnancy? I do exercise 3 times week and in my first pregnancy ran until 28 weeks - my diet will also change to include more healthy lifestyle. Any suggestions?

Dear Elza: It sounds like you are doing all the right things. Make sure that your thyroid medication is properly adjusted during pregnancy (Your TSH should be low normal) as doses change with pregnancy. Also try not to lose weight during your pregnancy. Make sure you get screened early (22-24 weeks, and then again at 26-28 weeks) for gestational diabetes - both because of your age and because your last baby weighed more than 10 pounds!

Kim: I am 40 years old and expecting my third child several years after the birth of my last one! What are my risks of pre-term labor since I am older? Also, I had a LEEP procedure about one year ago will that increase my risk?

Dear Kim: The increased risks of spontaneous preterm birth are only slightly higher as women age. Preterm birth does increase, but it is usually due to what doctors call "indicated" preterm birth (meaning that early delivery is necessary due to medical complications of the mother that may also affect the baby). If you are healthy, without high blood pressure or diabetes, and you didn't have preeclampsia or preterm birth in your other two pregnancies, then your risks are relatively low. While the LEEP procedure can sometimes shorten the cervix, most women who have had a LEEP don't have any problems. If you are concerned, your OB can check your cervical length periodically during your pregnancy (between 18 and 23 weeks) to make sure that you don't have shortening. If your cervix does start to shorten or open, a stitch (cerclage) can be placed to help hold the cervix closed. However, most OBs would not place a cerclage without seeing signs of shortening.

Tonya: I'm 38 years old and 11 weeks pregnant with my second child. I keep the temperature in the house at 66 degrees and have the window open at night. I wake up every night sweating profusely. Is this normal or does this mean that my body is overheating and can cause damage to my baby.

Dear Tonya: Many pregnant women feel very overheated because of the changes in blood flow to their skin. An increase in sweating is also common. However I suspect if you actually check your temperature that it will be normal, and that therefore your baby is not really being exposed to elevated temperatures. You do seem to be having some significant symptoms! I would recommend that you have your thyroid function checked to make sure you don't have an overactive thyroid. Along with the usual prenatal labs, I would also get a tuberculosis skin test which is safe in pregnancy. Although unlikely, night sweats can sometimes be a sign of tuberculosis. Most likely, though, everything you are experiencing is normal.

Susan: I will be 38 in May and want to get pregnant. I am in excellent shape. I work out 3-4 days a week, do not drink or smoke and eat very healthy food. I also have had a normal birth. My son is now 9. Because of my excellent health, does my chance of an abnormal pregnancy decrease?

Dear Susan: Underlying good health is always important to a healthy pregnancy. Keeping in shape decreases some of the most likely complications of pregnancy including high blood pressure and diabetes. Therefore your risks are probably significantly lower than the average 38 year old, but still may be a bit higher than what your individual risks were 9 years ago. Being healthy will not reduce your chances of chromosomal problems like Downs, though, so if you are interested in prenatal diagnosis I would still go ahead with either screening or testing (amniocentesis or CVS).

Mary: I'm almost 43 years old and I just found out I'm pregnant for the first time. I'm thrilled but scared of miscarriage, birth defects, etc., although I am in very fit health. I know a lot of people ask this, but given my age, would you recommend going straight for a CVS or should I have a nuchal translucency test done first, see what that says, and decide on a CVS or amnio from there?

Dear Mary: At 43 your risks of miscarriage and chromosomal problems are higher. Your age-based risk of Downs is 1 in 50 (2%) and of any chromosomal abnormality is 1 in 32 (3%). Because your age is factored into the screening tests like nuchal translucency, you are more likely to have a positive screening test (55%). On the other hand, first or second trimester screening (if performed by a reputable center) will detect if your baby has Down syndrome about 97% of the time.

These decisions are always very personal. The most important question you should ask yourself is whether or not you will be reassured by a negative screening test. If you feel comfortable with a significantly reduced risk, then go ahead with first trimester screening. If you will still worry, or if you have to know for sure, then go straight to CVS or early (15 weeks) amniocentesis.

Orla: I am 39 and 10 weeks pregnant with my first baby following Frozen Embryo Transfer. The embryos were frozen when I was 37, but I am scared that I am a high risk for fetal abnormalities. Are my risks based on a 39 years old or 37 year old when the eggs were frozen?

Dear Orla: Your risk should be the risk from when the eggs were frozen. Therefore your risk of Down syndrome is 1 in 227 (< 1/2 %) and your risk of any chromosomal abnormality is 1 in 130 (<1%). Older age doesn't usually substantially increase the risk of other birth defects.

Wendy: I am 38 and a mom of three kids. My husband and I would love to have a fourth child, but I am somewhat afraid of conceiving twins as I know my chances are higher given my age. I know you can't look into a crystal ball for me, but how realistic is my fear? I don't feel prepared to have 5 children! Any advice or words of wisdom would be appreciated. We will not be using fertility treatments.

Dear Wendy: You do have an increase risk of spontaneous twins (or god forbid triplets) but that risk is still relatively small. At your age, the risk of conceiving twins without fertility treatments is about 2 to 3% . This is much higher than the risk of having twins at <35 years old (around 1%) but still isn't high enough to keep you awake at night (or from getting pregnant)!

Tammy: I am 43 years old and expecting my first child. I am 14 1/2 weeks along. This is my third try to carry; I lost my first one at 4 weeks, and the second one I lost at 13 1/2 weeks. I am concerned about having an amniocentesis. I know it tells you whether you have a Down syndrome baby and other defects but my concern is if I do have a problem with the baby there is nothing that can be done, right? I will accept this baby no matter what so my question to you is it ok to not have the amniocentesis? I just want to carry this baby to full term so I can become a mom. Am I wrong in not wanting to have the procedure done?

Dear Tammy: Making the decision to have an amniocentesis is an intensely personal one and there is no right answer. If you have decided that you are not going to act on the results then it is perfectly reasonable not to have the amniocentesis. You are correct that chromosomal abnormalities are not fixable, so the decision usually revolves on whether or not you want to continue with the pregnancy or not. On the other hand, some women feel better and have a better birth experience knowing what to expect before hand. In your case, however, the fear of miscarriage seems to override the emotional benefit you may have from this knowledge.

Allison: Is the test they do to check the fluid behind the neck sufficient to rule out Down syndrome? I am petrified of an amnio. I am 39 and 11 weeks pregnant.

Dear Allison: Screening tests are not yes/no tests; they are "more likely" or "less likely" tests. A normal first trimester test (nuchal translucency) will make it much less likely that your baby has Downs but will not rule it out 100%. In someone of your age, the first trimester test will detect about 95% of cases of Downs. Conversely, the test will come back as "low risk" in about 5% of babies with Downs. Each woman responds differently to these numbers. Some choose to go with amniocentesis or CVS, some choose to go with screening. Both are reasonable options.

Beth: I am recovering from a miscarriage at 5 weeks - my first pregnancy and I am 37. How long do I have to wait until we try again, and what are my odds of miscarrying again?

Dear Beth: There are no studies that have determined the precise amount of time that you need to wait until you try to become pregnant again. In my opinion, you will not be increasing your chance of recurrent miscarriage if you try again soon. More importantly, however, is your emotional state. Only you will know when you are ready to handle the rollercoaster moods that are likely to accompany your next try. Go ahead and try when you are ready. Having one miscarriage is common, and does not increase your risk of recurrent miscarriage. The chance of miscarriage does increase somewhat as we age, but in most cases you should still expect a healthy pregnancy. Good luck!

Natalie: At age 40 I miscarried with a blighted ovum at 10 weeks. I'm turning 42 next month and am now 5 weeks pregnant. What are the chances of having another blighted ovum? This will be our first baby.

Dear Natalie: In most cases your pregnancy should go forward and develop normally, however it's still too soon to tell. By six weeks, your OB should be able to see a fetal heart rate if everything is going well. If the heart rate is normal, you are in very good shape. You should know very soon. I'll keep my fingers crossed and hope for the best for you.

From Dina: I am going to be 36 this year, and I have had 2 miscarriages--1 at 9 weeks and 1 at 4 weeks. I am pregnant for the third time and I'm worried that I'm going to start bleeding any day now. If I miscarry again, what is my next step? In vitro? I have no problem getting pregnant, just can't keep the egg implanted. I have been tested for hormones, my lining, etc. and everything is normal. I never drank, do not smoke and am only a little overweight. My mother had very easy pregnancies; I was actually born in a car. Can you give me any advice as to what my next steps should be if this pregnancy does not take for the third time? Thank you so much.

Dear Dina: A history of miscarriages can be extremely nerve wracking! I don't know the details of your 9 week loss, but it is very uncommon to have a miscarriage once you have had a first trimester ultrasound that shows a normal fetal heart rate. This is because most miscarriages happen because of a chromosomal abnormality in the developing fetus or another major abnormality that prevents normal development. While some women do have repetitive miscarriage even after seeing a normal fetal heart rate, this is the exception rather than the rule. If you have had a normal ultrasound, I would try to relax. In the unlikely event that you do miscarry again, I would immediately go to see a reproductive endocrinologist for a workup of recurrent pregnancy loss. Usually in vitro fertilization is not necessary both because there are other potentially effective and less expensive options, and because in vitro is unlikely to be helpful. Good luck with this pregnancy; I will be hoping for you!

From Violet: Will my care provider treat me differently if I am over 35 when pregnant? How might my age affect the care I receive?

Dear Violet: Most of the time your provider shouldn't treat you especially differently if you are over 35. One difference you might notice is that you may be offered more tests for the detection of chromosomal abnormalities. For example, by being over 35 you have the option of proceeding directly to CVS (chorionic villus sampling) or amniocentesis if you want to. Women under 35 are generally offered screening tests only. If you don't want CVS or amniocentesis, you can still opt for a screening test or no testing instead. In addition, women over 35 are more likely to develop diabetes during their pregnancy, so your provider should test you for this condition. Not all providers screen women under 35 routinely. Other than that, your pregnancy is not especially high risk unless you have other medical conditions or end up becoming pregnant with twins or more!

From Jennifer: I am 34 1/2 and pregnant, due in October (when I will be 35). Should I do all the testing required of a 35 year old just to be safe or is there too much risk?

Dear Jennifer: Only you can decide how much risk is too much; it's different for every woman! If you will be 35 when you deliver, your risk of having a baby with Down syndrome is 1 in 385 and your risk of any chromosomal abnormality is 1 in 204. You can compare this risk to the 1 in 200 to 1 in 400 risk of miscarriage after amniocentesis. If you want the information and the risk of amniocentesis sounds relatively low to you, then you can go ahead with the amniocentesis. If the risk of chromosomal abnormalities sounds low to you and you are worried about miscarriage you can decide against amniocentesis. Another option is to determine your personal risk (as opposed to your age based risk) by undergoing screening for Down syndrome. If you are less than 14 weeks you can have first trimester screening. If you are more than 15 weeks but less than 22 weeks you can have second trimester screening. Then you can base your decision to have an amniocentesis (or CVS) on your individual test results.

From Nora: I am pregnant and 37 years old, and I am trying to decide whether or not to have the amniocentesis testing done. What are the risks vs. the benefits of this test? What should I be considering in my decision?

Dear Nora: The benefits of amniocentesis are that you will know for certain whether or not your baby has Down syndrome or another chromosomal abnormality. You can then use this information either to prepare yourself emotionally and financially and to educate yourself about Down syndrome, or you can use the information to decide not to continue your pregnancy. The risks of amniocentesis are a 1 in 200 to 1 in 400 risk of miscarriage. The decision making process is different for each woman. Many women consider their desire to know for sure, their anxiety level, their fear of miscarriage, their feelings about Down syndrome, religious beliefs about abortion, etc. while making their decision. Your partner's opinion can also be helpful in many cases. It's a tough decision, and there is no right answer.

From Mickey: I am 37 and pregnant with my second child. I had my first child at 35 and was not very worried about the risk of Down syndrome. But now, the worry is getting the better of me. What are the changes in risk as one gets older? Many thanks.

Dear Mickey: While the risks of Down syndrome do escalate as we age, the odds are still on your side. Your risk of giving birth to a baby with Down syndrome was 1 in 385 at 35 and is 1 in 227 now that you are 37. If you will be 38 when you deliver your risk is 1 in 175. Similarly your risk of having a baby with any chromosomal abnormality was 1 in 204 at 35 and is now 1 in 130 at 37 (1 in 103 if 38). What this means is that more than 99% of the time your baby will be normal. However, if anxiety is torturing you, going ahead and getting an amniocentesis may be the best individual decision. This way you can stop worrying (at least about that) and enjoy your pregnancy!

From Ellen: My husband and I just learned that I am pregnant. We are excited about the baby (our first), but we are both over 35 and pretty settled in our careers, so I am a little concerned about how a baby will change our lives. How can we prepare ourselves for this wonderful change?

Dear Ellen: I don't think that I could ever explain how much your life changes when you have a baby. It's incredibly amazing, a phenomenal amount of work, and a complete reordering of your priorities (not to mention the sleep deprivation)! The best way to prepare yourself is to spend a lot of time with any of your friends who have an infant or a small child. This will give you a taste of what it is like as well as some practical hands on experience. Another thing you can do is spend a lot of time talking as a couple about what is important to you both. I would make a list of a few things that are important and that you want to preserve (if possible!). In addition, I would make a list of things you think are going to have to change at work and at home, and figure out between the two of you how that's going to work. For example, each of you should be able to preserve one or two sacred things like a (short) date with a friend or some sort of exercise. At the same time, you need to work out the nitty gritty of who is going to be responsible for what. For example, who is going to adjust their schedule to go in later so that you can drop the baby off at daycare or wait for the nanny to arrive? Who is going to be responsible for taking your baby to doctor's appointments, etc. Who is going to come home a little early? Who will stay home (or how will you alternate) if your baby is sick? Who will do the shopping? Who will do what housework? With two working individuals who want to continue in their careers, I have found that the key elements to making this work are balance and compromise. Even if you think you have divided things fairly and you have open communication with your partner, resentments will arise! If possible (and I'm terrible at this) it's also nice to try to schedule a date with your partner every 2 weeks so that you can have some time together. Good luck!

From Kari: I am 36 and want some information on the quad marker blood test. My OB/GYN recommends me to have it. I have read that if the results are positive that I have a higher risk of having a baby with an abnormality, but it doesn't necessarily mean that I WILL deliver a baby with an abnormality. Basically, it will just raise my concerns over the next 6 months. I am worry wart anyway, so I don't know if I should take this test or not. What do you think?

Dear Kari: The quad test measures the levels of four substances in your blood (estriol, human chorionic gonadotropin, alpha-fetoprotein [AFP], and inhibin-A). These results are combined with your age in a complicated formula that gives you a personal risk of Down syndrome. This final risk can be higher or lower than your age based risk (1 in 294). The test is "positive" if your risk is greater than the risk of a 35 year old (approximately). One way to think about it is that you already have a "positive" screen right now based on your age. If you get the test, about 85% of the time it will come back "negative" and that may be reassuring to you. If the test comes back positive, your chance of Down syndrome varies, but overall is between 1 in 34 to 40. Would a positive result make you want to go ahead with an amniocentesis? You will have to balance all this information in your mind. Odds are that your test will return negative, and this may be reassuring to you. Only you can make the right decision for yourself.

From Amy: I am pregnant with my second child and I am 39. I have had a nuchal done. It came back 1 out of 10,000. Should I go ahead and have a amnio also? This has been a very difficult pregnancy.

Dear Amy: I'm assuming you had both a nuchal translucency and a first trimester blood test (you need both for first trimester screening). If your risk came back as low as 1 in 10,000 then it is very unlikely that your baby has Down syndrome. I would only recommend an amniocentesis if you are consumed by anxiety about your risk, or if you absolutely have to know. Otherwise, I would forgo amniocentesis as it's far more likely that you will have a miscarriage (1 in 200 to 400) than that you will find out your baby has Downs (1 in 10,000).

From Dara: I am newly pregnant, about 5 weeks along. I had a pinkish discharge earlier in the week which prompted the doctor to do a sonogram. It showed one "regular" sac, and possibly one "irregular" sac, indicating a possibility of twins, as per the doctor and the sonogram tech. Would an irregular sac indicate something wrong with the baby or possibly mean that baby is not viable? Or is it possible that it's not really a sac at all? I just turned 35 and I'm having a hard time knowing what to think? Please share any information you may have about my situation. Thank you.

Dear Dara: Unfortunately these ultrasound findings can mean many things! You are very early in your pregnancy and it will be hard to determine exactly what is going on for another 1-2 weeks. Most likely, you will end up being pregnant with one baby. The irregular sac is probably either a second twin that is not developing properly (and will be reabsorbed into your body) or it could be a small area of bleeding that explains the spotting you have had. Less likely, you are pregnant with twins and both are developing normally. Twins are more common after 35, even if you didn't take any medications to help become pregnant! Your physician probably recommended another ultrasound in 1-2 weeks. At that point everything should become clear . . .

From Amy H: I am pregnant and will deliver 3 months before my 35th birthday. I stopped taking the pill and was pregnant before my next cycle. I want to have another baby within the next two years. Will my chances of conceiving go down dramatically or will I have as easy a time of getting pregnant as I did for this pregnancy? Thanks so much.

Dear Amy H: Certainly the fact that you were able to get pregnant so easily this time is a very positive sign. It is likely that you will be able to get pregnant again at 36-37 without difficulty. But there are no guarantees in life, since the ease of conceiving does decrease with age and the risk of miscarriage increases. However I think having at least 18 months between deliveries is a good idea, both medically and mentally - so I think your plan is a good one.

From Diane: Do I need a CVS or amniocentesis with a third pregnancy if I've already had two successful pregnancies? I just turned 35. What are the risks of miscarriage in the first trimester in a healthy, over 35 pregnancy?

Dear Diane: No one ever "needs" a CVS or amniocentesis; it's a personal decision for each woman as they weigh the small risk of having a baby with Down syndrome against the small risk of miscarriage with CVS or amniocentesis. Unfortunately, the fact that you've had two successful pregnancies doesn't decrease your risk of having a baby with Down syndrome, since this is based largely on your age. If you have just turned 35, your age-based risk of having a baby with Down syndrome is about 1 in 385 at delivery.

First trimester screening, that combines an ultrasound (to look at the thickness of the "nuchal translucency" at the back of your baby's neck) with a blood test will give you a more accurate idea of your personal risk. Your options are: 1) First trimester screening 2) Second trimester Screening (Triple or Quad Test) 3) No screening, but go ahead with a CVS or amniocentesis or 4) No screening and no testing.

If you decide to get screened, you can base your decision on whether to have a CVS or amniocentesis on the results of your screening test. The risk of miscarriage is very low once you have had an ultrasound that shows a normal heart beat. The risks of miscarriage before ultrasound are hard to quantify since many women miscarry before they even know they are pregnant.

From Melanie: I am 43, overweight with high blood pressure and I'm pre-diabetic. My husband and I want to have another child; we have a 2 year old son and would love to give him a sibling. Am I crazy for wanting to get pregnant again considering my health isn't the greatest right now at my advanced age? I'm really scared about eclampsia and pre-eclampsia as well as all the other problems that an older mother could face during pregnancy.

Dear Melanie: I'm not sure what you mean by "pre-diabetic." If you have elevated blood sugars, your risk of miscarriage and birth defects will be less if your blood sugars are treated before you try to become pregnant. It's true that your risk of pre-eclampsia is higher if you already have high blood pressure. However, if you didn't develop pre-eclampsia in your last pregnancy your risks are less.

As a maternal fetal medicine specialist, I only rarely tell women not to attempt pregnancy. The chances are that you would have a healthy pregnancy, but it will take a lot of work, carefully checking your blood sugars four times a day and taking medication to make sure your blood pressure stays in the normal range. In addition, you have a good chance of ending up on bed rest during your pregnancy, which is quite difficult with a 2 year old.

However, if you are up to it, I would suggest a pre-conception visit with a maternal fetal medicine specialist to review your risks: chromosomal abnormalities, gestational diabetes/diabetes, high blood pressure, pre-eclampsia. The more information the doctor has about your personal history, blood pressure, etc, the more accurate idea he or she can give you about your personal risks as well as making a plan to maximize your chances of a healthy pregnancy including: adjusting your mediations and normalizing your blood sugars.

From Stacey: I had my first daughter by emergency Cesarean (cord prolapse kind of situation) just a week shy of my 38th birthday. When/If we decide to have another child, I will be at least 40 at the time of delivery. I am interested in pursuing a VBAC but I've noticed recently that one of the things on the VBAC no-no list, along with things like breech presentation and twins, is maternal age over 40. I am a very healthy person and my last pregnancy was a dream -- no morning sickness, no backaches, none of the usual pregnancy-related complaints. My OB and my midwife both said they would prefer a dozen "old moms" over one 20-year-old who smokes and lives on Pepsi and Cheetos. Obviously no pregnancy is the same as any other, but assuming that I continue to be healthy and I have an uncomplicated pregnancy, is there any medical reason why a healthy 40-year-old should NOT be allowed a trial of labor? Thank you.

Dear Stacey: The decision to attempt a VBAC should be yours in this situation. I don't think that maternal age over 40 is an absolute contraindication to attempting a VBAC. However, your chance of a successful VBAC does decrease somewhat as you get older.

From Dee: Both of my previous pregnancies resulted in breech births, one natural and one c-section. My obgyn has explained that it may be shape of my uterus. I am 37 and trying to get pregnant again. Do the previous breech births present a problem for an older mom? Also, should older moms look for a different multi-vitamin? Folic acid? Omega 3? I've had 2 bad pregnancies, 2 healthy children, and now I'm scared to become pregnant again. I am an otherwise healthy person, until I get pregnant. I was 18 with my first child, 26 with my second. I had strange "spotting" and sometime heavy bleeding with my second child that no one, including the high risk experts, could ever really explain. My doctor and my husband think I am worrying too much, but I can't help it.

Dear Dee: My measure of a "good pregnancy" is one where both the baby and the mother are healthy. Although many women report "dream pregnancies" I don't believe that pregnancy is discomfort- or worry- free for most! I'd need to know more about your personal history, but if both of your babies were born at full term, the fact that they were breech is not particularly worrisome since they both ended up being normal. With your third pregnancy, your chances of having a breech baby is high and you will likely end up with a second cesarean.

Some women do have continuous bleeding or spotting during their pregnancies. This may be from a small area of bleeding at the edge of the placenta that can be difficult to identify on ultrasound. If you've had bleeding like this in a previous pregnancy, there is an increased chance that it could happen again in a subsequent pregnancy, however, more likely than not, it will not recur. Most women this happens to don't have any risk factors, but there are some: smoking, cocaine use, and high blood pressure. If you smoke I would stop before you become pregnant! If you have high blood pressure, I would make sure it is under good control with medication.

All women who are trying to become pregnant should take a daily prenatal vitamin for the folic acid to decrease their chance of birth defects. No special vitamin is needed for older women. Studies that have looked at omega-3 supplementation in pregnancy have found minimal benefits in terms of reducing pregnancy complications (preterm birth, risk of pre-eclampsia) and the effects on childhood development is controversial. However, omega-3 supplementation in the form of fish oil is not harmful, and generally these supplements do not contain the mercury found in many fish. If you do take fish oil, make sure it is not oil derived from fish liver (like cod liver oil) as this can have too much Vitamin A. You can also get use algae-derived supplements or eat Omega-3-fortified eggs.

From Michelle: I am pregnant with my third child and I'll be 40 soon. I'm noticing a lot more spider veins than I've had with my first two pregnancies. Can I expect these to go away after I give birth? They really look awful! Thank you so much for taking the time to answer my question!

Dear Michelle: Your spider veins will probably get better, but they won't disappear! If they bother you, you can reduce their appearance with treatment: usually sclerotherapy or laser, but I'm not an expert in this. I usually recommend no treatment until you have decided that you are done with pregnancy because you don't want to undo the treatment you have had.

From Lori: I am 42 and struggling to conceive my second child. Our first child was conceived naturally just after I turned 39. Since his birth, I've had two miscarriages at 6 weeks and one at 12 weeks. I feel like the clock is ticking away and I'm running out of time. I would really like to have another baby. Should I seek advice from an RE at this point?

Dear Lori: At 42 with three miscarriages, you should see a reproductive endocrinologist right away. While your miscarriages may be related to your age, you should have a full workup to make sure that there is no other reason that this is happening to you. If a reason is found, then treatment may help you carry a healthy pregnancy.

From Bridget: I'm 39 years old and 9 weeks post partum (c-section delivery) with my third (and final!) child. The incision site is still quite puffy and tender. Is this normal and will it ever be flat again?

Dear Bridget: Usually by 9 weeks your incision should be well on its way to being healed, although healing does continue past this point. Serious problems like infection are rare at this point. You should have your OB examine your incision to make sure you don't have something called an incisional hernia. This is rare in bikini incisions, but more common with vertical skin incisions. Pain and numbness usually improve over time, and at some point your incision should be pain free and relatively flat. The healing process is different in each woman.

From Kim: I'll be 36 next month and I'm finally pregnant with my first child. I was wondering what type of testing might be available to determine genetic abnormalities? I would love to get the reassurance that everything is ok with my baby, but I really don't want to do anything invasive, like the CVS test or an amnio.

Dear Kim: Two types of screening tests are available to you, first or second trimester screening. First trimester screening combines an ultrasound (to look at the thickness of the "nuchal translucency" at the back of your baby's neck) with a blood test. Second trimester testing involves a blood test alone. Screening doesn't detect all babies with Down Syndrome, but it does pick up about 85%. Both tests will give you the numeric risk of your baby having a chromosomal abnormality. If your risk comes back higher than 1 in 300 - your test will be called abnormal and you will be offered further testing with CVS or amniocentesis. However because you are seeking reassurance you should know that, because your age is figured into the calculation, your test is more likely to come back abnormal than that of a 20 year old.

Depending on the kind of test you are having, the chance that your test with be abnormal is 15-20%. On the flip side, this means that 80-85% of the time you will get the reassurance you were looking for. If your test comes back abnormal you can use the information to decide whether or not you want testing. Some women decide to have a CVS or amniocentesis and some women decide not to; it's entirely up to you.

From Lynda: I am a Multiple Birth Educator and for women over the age of 30, and more specifically 35, research shows the risk of conceiving at least twins is significantly higher. This is helpful information for parents to be aware of. Does your book address the chances at all and/or provide appropriate resources should parents become pregnant with multiples? Thanks, Lynda

Dear Lynda: It is true that the chances of a multiple birth increase with age, both in women who conceive spontaneously and because of assisted reproductive technologies (ART). My book talks about the risk of multiples with ART but women should know that you don't have to have in-vitro fertilization, more multiple pregnancies are the result of medications like Clomid alone.

My book also discusses the increased risk of multiple gestations as women get older, but does not give an exact number since it is different for each woman based on her specific age. The book does review the risks of pregnancy complications like preterm labor and gestational diabetes for women with multiples as well as what may happen in labor. However, for women who conceive twins or triplets, I would suggest a more specialized book that goes into lots of detail!

From Maura: I am 38 years old and just found out I am expecting my first baby! I am considering having a CVS screening to check for any genetic abnormalities. Can you explain how this procedure is done? What are the risks associated with it? Would it be safer to have an amniocentesis? Thank you for any information.

Dear Maura: Congratulations on your pregnancy! CVS is short for chorionic villus sampling. Chorionic villi are fragments of placental tissue, which used for laboratory testing. The placenta comes from the fertilized egg, so the chromosomes in the cells that make up the placenta are representative of your baby's chromosomes. During CVS, a small amount of tissue from your placenta is removed and tested. CVS is generally performed between 10 and 12 1/2 weeks gestation and the results of the CVS are usually available in 7 to 10 days.

The CVS procedure is performed using ultrasound guidance so that the physician can see exactly where the placenta is located. The procedure can be performed either transabdominally or transcervically. In the transabdominal procedure, the needle used to collect placental fragments is placed through your abdominal wall, similar to amniocentesis. In the transcervical procedure, a slender tube (catheter) is placed through the opening of your cervix. Usually the physician will decide which approach her or she will take, based on the position of the placenta and the way the physician was trained. In about 2-3% of cases, the physician will not be able to perform the CVS procedure because of the position of the placenta. In these cases, your physician will recommend that you return for amniocentesis at 15 weeks gestation.

Although you may be afraid of the idea of a needle going into your skin, or a catheter into your cervix, CVS is actually not very painful for most women. It is common to have uterine cramps which are very similar to cramps you might feel during your menses. If you are having a transabdominal CVS, the needle usually doesn't hurt any more than it does when you have blood drawn although you may have some uterine cramping that feels like a menstrual cramp. Some physicians use a little bit of local anesthetic before the transabdominal procedure, but many do not because the local anesthetic itself stings.

As with most medical procedures, the risk of complications after CVS is dependent on the experience of the physician performing the procedure. In skilled hands, the risk of miscarriage after CVS is estimated at 1/200 to 1/300, slightly higher than the risk of pregnancy loss after amniocentesis (1/200-1/400). The rate of pregnancy loss after transabdominal CVS is not different from transcervical CVS.

Several years ago, reports appeared in the medical literature regarding women who had undergone CVS and subsequently delivered infants with limb abnormalities, including missing fingers or toes. It now appears that the majority of these cases occurred after CVS that was performed prior to 10 weeks gestation. Your underlying risk of having a baby with a limb defect without having CVS is about 1 in 1700. If you have a CVS procedure, your risk of having a baby with a limb defect may be slightly increased to approximately 1 in 1000.

One of the most important benefits of CVS is that it can be performed up to 5 weeks earlier than amniocentesis. In addition, because more genetic material is collected after CVS, the results may be available more quickly than after amniocentesis, decreasing the number of days you must wait anxiously for the test results.

Finally, in women who are afraid of amniocentesis, transcervical CVS may allow for prenatal diagnosis without a needle. Hope this helps!

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