Pregnancy After 40 with Dr. Shannon Clark
Dr. Shannon M. Clark is a double board-certified OBGYN and maternal-fetal medicine specialist focusing on the care of women with maternal and or fetal complications of pregnancy. She’s a professor and clinician, runs the popular Babies After 35 account on Instagram and is the TikTok Baby Doc. She also had her twins at the age of 43.
After finishing medical school at the University of Louisville School of Medicine in Kentucky, she completed a residency in OBGYN at Allegheny General Hospital in Pittsburgh, Pennsylvania.
During her first year of residency, she realized her passion for taking care of women with complicated or high risk pregnancies. She subsequently pursued a fellowship in maternal-fetal medicine and received a master’s in medical science at the University of Texas Medical Branch in Galveston.
I’m so thrilled to have her here to share her knowledge with all of us on what pregnancy after 40 looks like, how you can approach your fertility at this age and how to take the best care of yourself before and during your pregnancy.
Dr. Aimee: I am so excited to bring back Dr. Shannon Clark to talk to us about pregnancy after 40 from preconception to delivery.
Welcome back, Shannon.
Dr. Shannon Clark: Thank you for having me.
Dr. Aimee: You’ve recently co-authored this fabulous paper. When I read it, I was like I have to have Shannon on the show. It’s titled Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management from Preconception to Delivery. There’s a lot of ground to cover here. What set the ball in motion for you and your co-authors to write the paper?
Dr. Shannon Clark: One of my residents is going into Reproductive Endocrinology and Infertility (REI,) and he is incredible and a very good writer. I’m not so bad myself, but I’ve always wanted to do something like that. Being in academic medicine, whenever there’s something I want to write about, I always offer to have a resident or fellow be primary author because they need publications.
Christopher joined me and did a lot of work with our new PGY2. We co-authored the paper together. We also added Christopher’s dad who is in REI to get the board certified REI on board. It ended up being a really good paper and they made it a continuing medical education paper, which I thought was excellent, so providers who read it can answer questions and get some CME credits.
Dr. Aimee: I’m going to ask you a question and put you on the spot for a second here. What do you think is the age where you would say you’re too old to have a baby?
Dr. Shannon Clark: I don’t know. I don’t think that’s up to anyone to decide but the individual themselves. I think probably the older someone is, you have to think about your longevity and what might happen. Of course, anybody’s longevity can be cut short at any point in time. I think when you start pressing past 50, that’s probably the biggest consideration, assuming that you’re physically well enough and healthy enough to undergo a pregnancy.
Even at 42, almost 43, when I had my twins, I worried about that a little bit. But I don’t think it’s up to anyone to judge. I really don’t.
Dr. Aimee: I couldn’t agree with you more. Someone asked me that question today when I was giving a talk to an MBA program. I literally said, “If you think you’re too old, you’re too old. And who am I to judge?” That was word for word my answer, so that’s fun to hear you say that.
Advanced maternal age is defined as pregnancy over 35. We’ve talked about pregnancy after 35 together in previous recordings that we’ve done. What should be included in preconception counseling after 40?
Dr. Shannon Clark: I think one of the big things to consider is that more and more individuals are delaying childbearing. We have people who are not becoming parents first, and I think that’s perfectly fine. People have the right to pursue education and other training. However, you also have to be knowledgeable about the potential implications of delaying childbearing.
If anyone is approaching age 40, especially if they have never had a child, incorporate that discussion into your yearly OBGYN visit or gynecologic visit. I think the provider should bring it up. We’re not quite there yet, it’s not included in our checklist for our well woman exam, and it probably should be. If not, then the patient should bring it up.
We need to assess what your periods are like, are you still having a period every month, make sure we have that egg quality versus quantity discussion, if there are any pre-existing medical conditions that may or may not require medications, and if they do require medications, we need to look at those medications and make sure they’re pregnancy compatible. I don’t like to say safe or not anymore because we don’t even use those categorizations. What we should be doing is discussing the risk-benefit ratio of each individual medication that someone might be on to determine if A) the medication might need to be changed in anticipation of becoming pregnant or B) that the dosage might need to be changed or adjusted.
The reality is as we approach our 40s, a lot of people are going to start developing medical conditions that need to be treated. Mental health, hypertension, diabetes, and all those things should be evaluated in a preconception consult. I also think it’s a good idea, and what the paper showed, to potentially get a cardiac evaluation, too. One of the biggest physiological changes is on the cardiovascular system with pregnancy, and we would want to make sure a baseline EKG looks okay before getting pregnant, ideally if we can, in that age group.
Just having the basic talk with people in that age group about what pregnancy might look like after age 40, even if you’re a healthy person, the risks associated with pregnancy after age 40. Being as knowledgeable and informed as possible is only going to help.
Dr. Aimee: What are some of those risks of getting pregnant over the age of 40?
Dr. Shannon Clark: The first potential barrier is getting pregnant. I hear a lot of, “My aunt (or mom) had a baby at 45 with no issues. I’ll be okay. I can do that.” Or, “If I can’t get pregnant on my own, then I’ll just go to IVF.”
I think that people have to understand that fertility is not inherited. You can’t assume that just because someone in your family was able to successfully and easily conceive at 40+, that you will. Even if you’re having regular monthly menstrual cycles, which is one of the most important things you need to spontaneously conceive, it doesn’t mean that the egg quality is going to be there. I’m a prime example. When I did my five cycles of IVF, I got a bunch of eggs that were chromosomally abnormal, and I was healthy. So, that’s something to consider.
As far as falling back on IVF as a valid plan B, yes, there’s IVF and multiple things you could do with assisted reproductive technology, but IVF doesn’t work for everyone. It didn’t work for me. I went through five cycles, and I had to actually end up using donor eggs. You can’t be falsely reassured by those things. We just have to be realistic. Again, be as informed as possible to make those decisions with as much information as we can.
Dr. Aimee: You mentioned getting an EKG for women over 40. Do you think that’s for all women over 40, or maybe over 45?
Dr. Shannon Clark: I think that especially if people have pre-existing medical conditions like hypertension and diabetes, that would be a good idea. It’s not going to hurt to get it on everyone. Do I think that every 40-year-old needs to get one? No. I think it’s mostly if anyone has pre-existing medical conditions, I would do that just to make sure everything looks okay. If they have long-standing chronic hypertension and they haven’t even had an echo in a while, I would probably get an echo on those patients because we need to make sure that the heart looks okay. That’s what we recommended in the paper for those who are over age 40.
Dr. Aimee: What are the different strains on the body, the stressors that can happen for someone over 40 who is pregnant, how is that different than let’s say for someone who is 30?
Dr. Shannon Clark: I think even when we’re not pregnant, we know how our bodies change with age. Just think about adding the pregnancy on top of that. The physiological changes there are pretty much the same. It’s just that our bodies might respond a little bit differently, or we as an individual might respond a little bit differently.
It’s just a matter of making sure that we’re at a healthy weight, that if we have chronic medical conditions under control with or without meds. If they require medications, that’s fine, we can still have a successful pregnancy on medications. Making sure that we’re in the best possible health we can before even getting pregnant, ideally. The time to play catch up is not once the pregnancy is here. I know that happens, people have surprise pregnancies, and there’s not a whole lot you can do about it. If we have the option to get you under control before the pregnancy, that would be my preference.
Dr. Aimee: The paper mentions assisted reproductive technologies. For those people listening who don’t know what that is, it basically means doing IVF. Do you think every woman over the age of 40 should just go right to seeing an IVF doctor?
Dr. Shannon Clark: There’s the science part of me that says yes. Then there’s the not-science part that says maybe not. So, this is what I would say.
I would say if you are 40+ and you are having regular monthly menstrual cycles, you could possibly get away with waiting three months, maybe, to conceive on your own spontaneously, and if not, then going. But if you have other medical conditions that could affect your fertility, if you’re not having regular monthly menstrual cycles, I would not wait, I would go right off the bat. If for nothing else, just to get a baseline evaluation and get some information from the fertility specialist about what to expect.
I remember when I went with my husband, and I’m an OBGYN, I told my friend who is my fertility doctor, “Talk to us as if I’m not a doctor, just lay it out.” My husband was sitting there like… It was daunting and it was scary, but he needed that information. If for nothing else, just going and getting that information and that knowledge is going to help.
I would always err after age 40 on being seen sooner than later. I’ll say this every chance I get; it doesn’t mean they stamp IVF on your forehead and put you in line for IVF. Sometimes it’s just a matter of doing some investigation and tweaking things and making recommendations, even over 40. Then there are times that IVF is needed. Don’t delay going to an REI doc for an evaluation because you’re scared of being told something bad or that they’re just going to sign you up for an expensive IVF treatment.
Fertility doctors are very good about educating and letting people know what their options are. I think for the most part REIs want to get you pregnant and start your family and family building in the least invasive and least costly way possible. That’s my experience, anyway, and what I hear from talking to people. So, go sooner than later.
Dr. Aimee: The other thing is especially if you want a larger family and you don’t have a baby at home, believe it or not, 40-year-olds can potentially still bank embryos so that they can have two, even three children. Just because you did IVF doesn’t mean you have to use your embryos right away. I tell patients let’s just do IVF, freeze an embryo, and then you can try at home for a while. It’s just nice to know that you’ve done some work to give yourself a higher chance of pregnancy in the future. All great points.
What about the first trimester of pregnancy, what do women over 40 need to know about that?
Dr. Shannon Clark: In the first trimester of pregnancy, especially over age 40, there is an increased risk of miscarriage or pregnancy loss, mostly due to chromosomal differences in the developing embryo. It’s much greater as you get over 40, and then definitely over age 45 the risk of pregnancy loss and of early pregnancy loss is much greater.
The other thing I hear all the time in all age groups, but even in those that are of an older age, is that they don’t want to do antenatal screening. That’s where we draw blood tests to look for an individual’s risk of the fetus having a chromosomal difference or something else. I think some people think that if they do that test and it’s abnormal that it means they’re going to do a termination, and that’s simply not true.
I highly recommend that anyone, especially those of an older age or an advancing age, get the antenatal screening. What I see so many times is they decline it, they come in for an ultrasound, and I might see not necessarily a major birth defect, but something that we call minor markers. These are things that are not birth defects, but can alter an individual’s risk of having a fetus with a chromosomal abnormality. It’s so much easier to counsel and make it make sense when I have the results of antenatal screening because it’s much more digestible when I can give them what the risk is in numbers. I can’t do that as easily when they don’t have antenatal screening.
So, I highly recommend antenatal screening. It does not mean that if it’s abnormal you’re going to terminate, or if it’s abnormal that we have to do the amniocentesis. That’s always your choice. It’s not going to hurt anything to have the information.
Then early pregnancy dating, getting an ultrasound as soon as possible to get accurate dating. The best way to date a pregnancy is not even knowing your last menstrual period. The best way to date a pregnancy is with that early first trimester ultrasound, because up to 60% of people, 65% even, are actually incorrect about what the first day of their last menstrual was. Getting that early ultrasound is key.
Obviously, if the preconception workup was missed because it was a surprise pregnancy, then the first trimester is going to be a time when we’re going to have to do the testing that we need, evaluate medical history and any medications you might be on, to get all those things under control and in order for the rest of the pregnancy.
Dr. Aimee: What about the second trimester, what do women and providers need to know about that timeframe in pregnancy?
Dr. Shannon Clark: The anatomy scan is key. That’s a detailed anatomy scan, and it’s typically done at 18 to 22 weeks. I like to do it on the early side if I can, meaning 18 to 20 weeks if I can get the patient in then. That’s where we look for any major birth defects, because patients over the age of 40 are at increased risk for having birth defects in the fetus. Then we’re looking for the minor markers, which I described before. So, people over age 35 and over age 40 are going to have what’s called a detailed anatomy scan.
I would definitely send the patient for a genetics consult just based on age alone, but especially if there are other things that are going on in the medical history that would warrant a genetics consult. Also, once you start getting into the second trimester and the physiological changes in pregnancy are in full swing, if you have diabetes or high blood pressure, that might be a time when any pre-existing medical condition might start to be a little bit harder to control, or you might need to start adjusting medications or adding medications. All of those things need to be watched in the second trimester, especially in someone who is over age 40.
The other thing, I don’t want to scare people, but it’s a reality, is stillbirths. Stillbirth is a pregnancy loss after 20 weeks of gestation. Patients over age 40 are at increased risk of stillbirth, so making sure the patient is informed about that is important. If there are medical comorbidities that would require antenatal testing, get that implemented. Following with growth scans if we need to, or growth ultrasounds to assess the growth of the fetus. All of those things are what we need to start considering once we hit the second trimester.
Dr. Aimee: What are your thoughts on a patient having their own blood pressure cuff at home, is that something that you recommend to your patients?
Dr. Shannon Clark: I do. As long as they have the right size and they know how to do it, and they actually do it and log it. If you’re doing it the right way, absolutely.
I think it’s a tool. I don’t want them to get too preoccupied with it. I just tell them to do it a couple of times randomly throughout the day when you think about it. You want to get it in different scenarios, not just once they’ve been sitting down and resting for a while. You want to get it when they’re active and when they’re also resting, so I can get a range of what’s going on.
If your provider recommends that you do at-home blood pressure monitoring, the most important thing is making sure that the cuff on the blood pressure machine is the right size because you can get falsely elevated blood pressures if the cuff is too small.
Dr. Aimee: What about aspirin, do you recommend that for your patients over 40?
Dr. Shannon Clark: Yes. Anyone over age 35, that is considered a moderate risk factor. You would need two moderate-risk or one high-risk factor for being on baby aspirin. Most individuals over age 35 are going to fall into the category where they would start a low dose aspirin for the prevention of preeclampsia.
Again, it is for prevention of preeclampsia. A lot of doctors just give it to give it, and I don’t agree with that. They need to meet the criteria to get it. Most advanced maternal age individuals are going to meet the criteria to start on low dose aspirin.
Dr. Aimee: At what gestational age do you typically have patients stop it?
Dr. Shannon Clark: You continue throughout the pregnancy, we don’t stop it. Those are the new recommendations.
Dr. Aimee: What about vaginal delivery? I think one of the things my patients want, especially when they’ve worked so hard to have a baby, I always think every delivery is natural, but you hear that term used a lot, but they really want to be able to have a vaginal delivery. What are your recommendations about whether patients should have a vaginal delivery or a c-section?
Dr. Shannon Clark: Absolutely vaginal delivery, no question. Unless there is a reason to have a c-section, a pre-existing medical condition, if they’ve had a c-section before and they want to repeat c-section, there’s a placenta previa. Patients over age 40 are at increased risk for placenta previa or a placental abnormality, like a low-lying placenta. Then of course you’re going to need a c-section. Otherwise, vaginal delivery all the way.
Now, there is some study data that say that there is an increased risk of cesarean delivery and what we call a failed labor or arrested labor in those over age 40. We don’t know why, we haven’t figured that out, but if it happens, it happens.
I hear all the time, “My doctor said that I have to have a c-section.” Absolutely not. If there is a medical reason for it, sure, but not based on age alone. We should not be subjecting any individual to a major surgery in pregnancy just based on age alone, you have to have other reasons. I’m very pro vaginal delivery.
Dr. Aimee: Why do you think that providers in the past recommended c-sections?
Dr. Shannon Clark: It’s not in the past. They still do, I know they still do. I really don’t know, other than if they’re looking at the data that shows that patients have an increased risk of cesarean delivery anyway.
I will also say there’s a lot of patients over age 40 who want a c-section, who want an elective c-section or a c-section on maternal request. I’m for that, too. C-section on maternal request means there’s no medical indication for it, you just want it. If that’s the case, after discussing the risks and the benefits and what the potential complications are, I honor that. But I do think that we should not be making individuals who are older think that they have to have a c-section because that’s simply not true.
Dr. Aimee: What kind of trends are you seeing where you’re practicing as far as trends in women of an older age delivering babies, are you noticing any recent trends that you could share with us?
Dr. Shannon Clark: I’m in an academic center, so my patients are 90% indigent and underserved, so I don’t have a lot of patients who have undergone IVF, so I’m not seeing an uptick because of IVF. I know nationally that’s the case, but not in my specific patient population.
Someone asked me, today actually, what was the oldest patient I ever saw that got pregnant spontaneously. I think it was 52. That’s not typical, though. But I deliver patients over age 40 all the time that did conceive spontaneously.
Dr. Aimee: Thank you for all of your wisdom and thank you for shining a light on something that is obviously going to be so important to anyone over the age of 40 to listen to. Now that you wrote the article, Pregnancy After 40: Recommendations for Counseling, Evaluation, and Management from Preconception to Delivery, hopefully more and more doctors will read the paper and just know how we can take better care of women over 40.
Is there anything else that you want to share with our listeners?
Dr. Shannon Clark: Yes. One other thing that I think is important is the induction at 39 weeks recommendation for those over age 40. What do I think? I am very much for it, especially in patients over age 40. The risk of stillbirth, I think the stat in the paper was that a 40-year-old-plus at 39 weeks is equivalent to a 25-year-old at 42 weeks. The risk is there.
I would highly recommend getting delivered by 39, no later than 40 weeks. I am all for talking to the patient. If they want to keep going, that’s fine, and I will do some antenatal surveillance. But by and large, if I had my way, I would like to have those patients delivered no later than 40 weeks, ideally at 39 weeks. I do believe the data is strong enough to support that, especially in patients over age 40.
Dr. Aimee: Thank you. That’s incredibly helpful, especially coming from you, so that people can know how to advocate for themselves. Is that recommendation in your paper as well?
Dr. Shannon Clark: Yes.
Dr. Aimee: Excellent. People can print the paper, take it to their OBGYN, and say Dr. Clark said so, so it needs to be so.
Dr. Shannon Clark: There are a lot of doctors who do it and the patient is like, “Based on age alone, why do I have to?” Like I said, there are reasons why, but it doesn’t mean that you have to. It is a recommendation, it’s elective, that means the patient has to agree. I do not ever condone a physician scaring a patient into that and saying that something bad is going to happen or you should be accepting that recommendation.
It’s a recommendation and you have to have an exchange and dialogue and make that decision together, that’s called shared decision making and that’s what we should be doing as physicians. Most of the time patients will agree, but sometimes they don’t, and we have to respect that, too. As long as we’re informing them.
Dr. Aimee: Thank you again, Shannon. I really appreciate all that you’re doing. Where can people find you?
Dr. Shannon Clark: Like you said earlier, I am mostly active on Instagram @BabiesAfter35, but I’m on TikTok for the fun stuff. Those are the main places where you can find me, and at the website BabiesAfter35.com.
Dr. Aimee: Thank you so much. I really appreciate you taking time out of your super busy schedule as a professor and mom of twins to come on here and educate on all of the fabulous things you do and to talk to us. I hope you’ll come back again to talk with us some more. Thank you so much.
Dr. Shannon Clark: Thank you so much.
Originally published at https://draimee.org.
