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FCA-125
Peri-partum course of a 67-year-old elderly gravida

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Pregnancy and lactation in a 67 year old elderly gravida 

Sonal Zambare, MD

Intoduction:

There is limited data on the anticipated prenatal, intrapartum, and postpartum course among gravida over 45 years old, particularly among post-menopausal women in their 6th  and 7th decades. Here, we present a relatively uncomplicated case of pregnancy in a 67 y/o woman conceived by donor oocyte in vitro fertilization (IVF) and was also able to successfully breastfeed postpartum. This is the oldest gravida we found reported for a delivery at age of 68 years.

Case Report:

A 67 y/o G5P0040 conceived via IVF with oocyte donation from a presumptively healthy 22 y/o female and the 74 y/o husband’s sperm in West Africa.  

PMH: Significant for chronic hypertension, hyperlipidemia  maintained on simvastatin, and Class I obesity (pre-pregnancy BMI value of 32 kg/m2). Her chronic hypertension was well-controlled off medications at time of presentation, although one year prior to initiating IVF she was on an angiotensin-converting-enzyme inhibitor (Lisinopril).

Clinic visit:  At her first visit to our obstetrics high-risk clinic at 136/7 wga, she was initiated on daily aspirin 81 mg due to her increased risk of preeclampsia with plan for serial echocardiograms, comprehensive metabolic profile, brain natriuretic peptide, and 24-hour urine protein every 6 to 12 weeks. Subsequent visits during pregnancy were uneventful. Baseline echocardiography was initially delayed due to challenges in obtaining coverage for obstetrical indications under Medicare coverage, which she was mandated to due to her age. It was obtained in the early 3rd trimester.

Delivery: At 356/7 weeks of gestation, a new-onset II/VI holosystolic murmur was heard at the apex of the heart. These cardiac findings were accompanied by bilateral 2+ pitting edema in lower extremities, and worsening chronic hypertension with concern for superimposed preeclampsia. Repeat TTE was significant for minimal decrease in LVEF, and new onset trace mitral regurgitation. The shared patient-physician decision to proceed with primary lower transverse cesarean delivery was made under full and informed consent. Cesarean delivery was uneventful with successful delivery of female neonate, Apgar scores 7 and 9, weighing 2520 grams. She was 68 years-of-age at the time of delivery.

Anesthesia management: The obstetric anesthesia team was aware of this patient from weekly multidisciplinary meetings, and had provided ongoing input into her anticipated labor and delivery care. An uneventful single shot subarachnoid injection was performed. A satisfactory sensory level of T4 was obtained. Preservative-free intra-thecal morphine was used for post-operative analgesia. Fluid management during the Cesarean was kept conservative, and the patient was monitored closely for post-operative respiratory depression and other rare post-anesthetic complications such as nerve damage, infection, and/or post-dural puncture headache for the next 24 hours. This patient had an uneventful post-anesthetic recovery.

Postpartum course: Her postpartum course was uneventful with improvement of lower extremity edema and normotensive blood pressures not requiring additional medical management. She was discharged on POD # 3, and was successfully breastfeeding after lactation consultation.

At six weeks postpartum, her Pfannenstiel incision site was well healed, she continued to exclusively breastfeed, and showed no signs or symptoms of postpartum depression or cardiac compromise. Her blood pressure remained well controlled off of medications, and she planned for ongoing follow up with internal medicine for her chronic medical conditions.

Discussion:

This case brings forth several issues and topics fundamental to the care of elderly gravidae.

Increased maternal and paternal age:

-Increased risk of pregnancy loss, preterm birth, still birth, fetal anomalies, hypertensive disorders, gestational diabetes, multiple gestation, and cesarean delivery.
-Increased risk of placenta previa, postpartum hemorrhage, and adverse neonatal outcomes.
-Advanced paternal age has also been shown to be associated with multiple fetal anomalies, our patient elected for NIPT and fetal echocardiograms for fetal surveillance.

Mode & timing of delivery and intrapartum management:  

-Nulliparity and age >35 are independent risk factors for cesarean delivery.
-Monitoring of cardiac function led to decision about timing of delivery.

Anesthetic complications:

-Altered absorption, distribution, and clearance of the local anesthetics.
-Technical difficulties while placing the neuraxial block due to age related changes in the spine.
-Level of sensory blockade and the incidence of hypotension may be higher in the elderly with the same amount of intrathecal drug.
-The use of neuraxial morphine has been associated with an increased incidence of delayed respiratory depression after up to 24 hours in patients with advanced age.

Lactation:

-  Our patient was able to successfully breast feed in spite of reports of difficulty with lactation in advanced age.

Ethics:

-Assisted reproductive technology (ART) is usually discouraged in women with advanced age due to possible complications in mother and baby.
-Balance of patient autonomy (individual rights to make reproductive choices and access reproductive services) and nonmaleficence (utilizing medical advances to overcome natural limitations that may result in increased maternal risks and concerns about childhood welfare and early parental loss).
-Counselling is challenging.
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