Delayed Child-Bearing

doi:10.1016/S1701-2163(16)35138-6

Journal of Obstetrics and Gynaecology Canada

Volume 34, Issue 1, January 2012, Pages 80-93

https://doi.org/10.1016/S1701-2163(16)35138-6 Get rights and content

Abstract

Objective

To provide an overview of delayed child-bearing and to describe the implications for women and health care providers.

Options

Delayed child-bearing, which has increased greatly in recent decades, is associated with an increased risk of infertility, pregnancy complications, and adverse pregnancy outcome. This guideline provides information that will optimize the counselling and care of Canadian women with respect to their reproductive choices.

Outcomes

Maternal age is the most important determinant of fertility, and obstetric and perinatal risks increase with maternal age. Many women are unaware of the success rates or limitations of assisted reproductive technology and of the increased medical risks of delayed child-bearing, including multiple births, preterm delivery, stillbirth, and Caesarean section. This guideline provides a framework to address these issues.

Evidence

Studies published between 2000 and August 2010 were retrieved through searches of PubMed and the Cochrane Library using appropriate key words (delayed child-bearing, deferred pregnancy, maternal age, assisted reproductive technology, infertility, and multiple births) and MeSH terms (maternal age, reproductive behaviour, fertility). The Internet was also searched using similar key words, and national and international medical specialty societies were searched for clinical practice guidelines and position statements. Data were extracted based on the aims, sample, authors, year, and results.

Values

The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

Sponsor

The Society of Obstetricians and Gynaecologists of Canada.

Recommendations

1.
Women who delay child-bearing are at increased risk of infertility. Prospective parents, especially women, should know that their fecundity and fertility begin to decline significantly after 32 years of age. Prospective parents should know that assisted reproductive technologies cannot guarantee a live birth or completely compensate for age-related decline in fertility. (II-2A)
2.
A fertility evaluation should be initiated after 6 months of unprotected intercourse without conception in women 35 to 37 years of age, and earlier in women > 37 years of age. (II-2A)
3.
Prospective parents should be informed that semen quality and male fertility deteriorate with advancing age and that the risk of genetic disorders in offspring increases. (II-2A)
4.
Women ≥ 35 years of age should be offered screening for fetal aneuploidy and undergo a detailed second trimester ultrasound examination to look for significant fetal birth defects (particularly cardiac defects). (II-1A)
5.
Delayed child-bearing is associated with increased obstetrical and perinatal complications. Care providers need to be aware of these complications and adjust obstetrical management protocols to ensure optimal maternal and perinatal outcomes. (II-2A)
6.
All adults of reproductive age should be aware of the obstetrical and perinatal risks of advanced maternal age so they can make informed decisions about the timing of child-bearing. (II-2A)
7.
Strategies to improve informed decision-making by prospective parents should be designed, implemented, and evaluated. These strategies should provide opportunity for adults to understand the potential medical, social, and economic consequences of child-bearing throughout the reproductive years. (III-B)
8.
Barriers to healthy reproduction, including workplace policies, should be reviewed to optimize the likelihood of healthy pregnancies. (III-C)

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Directive clinique n<sup>o</sup> 441: Surveillance prénatale du bien-être fœtal
2023, Journal of Obstetrics and Gynaecology Canada
Résumer les données probantes actuelles et formuler des recommandations pour la surveillance prénatale du bien-être fœtal afin de détecter les facteurs de risque périnatal et toute potentielle décompensation fœtale et de permettre une intervention rapide en prévention de la morbidité et la mortalité périnatales.
Personnes enceintes avec ou sans facteurs maternels, fœtaux ou gravidiques associés à des risques périnataux et à la décompensation fœtale.
Utiliser des examens prénataux par technologie de base et/ou avancée en fonction des facteurs de risque de décompensation fœtale.
La reconnaissance précoce de toute décompensation fœtale potentielle permet d’intervenir de façon à favoriser l’adaptation fœtale pour maintenir le bien-être ou à accélérer l’accouchement.
Chez les personnes enceintes ayant des facteurs de risque périnatal confirmés, la surveillance du bien-être fœtal contribue à réduire le risque d’issue défavorable. Compte tenu du taux élevé de faux positifs, la surveillance du bien-être fœtal peut augmenter le risque d’interventions inutiles, ce qui peut avoir des effets nuisibles, dont l’anxiété parentale, l’accouchement prématuré ou assisté et l’utilisation accrue des ressources de soins de santé. L’optimisation des protocoles de surveillance d’après des pratiques fondées sur des données probantes peut améliorer les issues périnatales et réduire les effets nuisibles.
Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu’à janvier 2022, à partir de termes MeSH et de mots clés liés à la grossesse, à la surveillance fœtale, aux mouvements fœtaux, à la mortinaissance, aux complications de grossesse et à l’échographie fœtale. Le présent document est un résumé des données probantes et non pas une revue méthodologique.
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l’annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles).
Tous les membres de l’équipe de soins qui prodiguent des soins ou donnent de l’information aux patientes en obstétrique, notamment les spécialistes en médecine fœto-maternelle, les obstétriciens, les médecins de famille, les sages-femmes, les infirmières, les infirmières praticiennes et les radiologistes.
- 1.
  La reconnaissance précoce et exacte des facteurs de risque de décompensation fœtale permet aux professionnels de la santé d’élaborer un plan de soins individualisé afin d’optimiser le bien-être fœtal (moyenne).
- 2.
  L’examen de réactivité fœtale peut être utilisé conjointement avec l’examen du tableau clinique global pour évaluer le bien-être fœtal. L’examen de réactivité fœtale ne doit être utilisé qu’en présence d’une indication ou d’une constatation clairement associée à une augmentation du risque d’hypoxémie fœtale (moyenne).
- 3.
  L’échographie permet d’évaluer le liquide amniotique, le poids fœtal estimé, le profil biophysique et le profil biophysique modifié, et la vélocimétrie Doppler donne de l’information sur le bien-être fœtal dans les grossesses à risque de morbidité fœtale (moyenne).
- 4.
  La communication et la tenue de dossier au sein de l’équipe interprofessionnelle doivent être claires et utiliser la terminologie reconnue et définie (élevée).
- 1.
  Les fournisseurs doivent examiner et consigner les facteurs de risque périnatal (grossesses antérieures et facteurs fœtaux, maternels et familiaux) à la consultation initiale et mettre à jour les facteurs tout au long de la grossesse (forte, moyenne).
- 2.
  Les personnes enceintes doivent être informées des ressources locales et/ou de la nécessité de transférer des soins en fonction des facteurs de risque de la grossesse (forte, moyenne).
- 3.
  Les rencontres du suivi prénatal doivent intégrer l’évaluation et la tenue de dossier en consignant la présence de bruits cardiaques fœtaux, la taille de l’utérus, les inquiétudes et facteurs de risque liés à la grossesse, le plan de soins et la discussion avec la personne enceinte (forte, moyenne).
- 4.
  Il faut recommander aux personnes enceintes d’observer régulièrement les mouvements fœtaux à partir de 26 semaines d’aménorrhée (conditionnelle, faible).
- 5.
  Il faut aviser la personne enceinte de consulter son fournisseur de soins ou de se présenter à l’unité locale d’obstétrique immédiatement pour subir une évaluation approfondie en cas de diminution perçue des mouvements fœtaux, peu importe la technique de surveillance utilisée (forte, faible).
- 6.
  L’examen de réactivité fœtale doit être réalisé et interprété par des professionnels de la santé compétents (forte, élevée).
- 7.
  Il y a lieu d’utiliser une mesure de la plus grande citerne d’au moins 2 cm × 1 cm, telle que mesurée par échographie abdominale, comme critère d’évaluation du paramètre amniotique du profil biophysique (forte, modérée).
- 8.
  Pour assurer la sécurité des patientes, les fournisseurs de soins doivent élaborer des protocoles locaux clairs pour communiquer et consigner les changements de l’état fœtal observés pendant la surveillance prénatale du bien-être fœtal et pour exécuter l’escalade des soins (forte, moyenne).
- 9.
  Les fournisseurs de soins doivent recourir aux modes de surveillance prénatale du bien-être fœtal sortant du cadre du suivi de routine, tels que l’examen de réactivité fœtale, le profil biophysique et l’échographie Doppler fœtale, uniquement en présence d’une indication claire ou d’une observation associée à l’augmentation du risque d’hypoxémie fœtale (forte, moyenne).
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To summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality.
Pregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation.
To use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation.
Early identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery.
Antenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm.
Medline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. This document represents an abstraction of the evidence rather than a methodological review.
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).
All health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists.
- 1.
  Accurate and ongoing early identification of risk factors for potential fetal decompensation allows care providers to develop an individualized care plan to optimize fetal well-being (moderate).
- 2.
  The nonstress test (NST) may be used in conjunction with a review of the total clinical picture to assess fetal well-being. An NST should be used only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (moderate).
- 3.
  Sonography can evaluate amniotic fluid, estimated fetal weight, biophysical profile/modified biophysical profile, and Doppler blood flows to provide information regarding fetal well-being in pregnancies at risk of fetal morbidity (moderate).
- 4.
  Interprofessional team communication and documentation should be clear, using accepted and defined terminology (high).
- 1.
  Care providers should review and document perinatal risk factors (prior pregnancy, fetal, maternal, familial) at the initial visit and update factors throughout pregnancy (strong, moderate).
- 2.
  Pregnant individuals should be advised of local resources and/or the need for transfer of care based on pregnancy risk factors (strong, moderate).
- 3.
  Regular prenatal visits should include assessment and documentation of the presence of fetal heart tones, uterine size, pregnancy concerns or risk factors, the plan of care, and the discussion with the pregnant individual (strong, moderate).
- 4.
  All pregnant individuals should be advised to regularly monitor fetal movements starting at 26 weeks gestation (conditional, low).
- 5.
  If a reduction of fetal movements is identified, regardless of the technique used to assess fetal movements, pregnant individuals should be advised to present to their care provider or local obstetrical unit immediately for further evaluation (strong, low).
- 6.
  The nonstress test (NST) should be administered and interpreted by appropriately trained health professionals (strong, high).
- 7.
  A ≥2 cm × 1 cm pocket of fluid by transabdominal sonography should be used as the criterion for the amniotic fluid component of the biophysical profile (strong, moderate).
- 8.
  To ensure patient safety, care providers should develop clear protocols locally to communicate and document changes in fetal status identified during antenatal fetal surveillance and escalation of care (strong, moderate).
- 9.
  Care providers should use non-routine antenatal fetal health surveillance modalities, such as an NST, biophysical profile, or fetal Doppler sonography, only in the presence of a clear indication or finding associated with increased risk of fetal hypoxemia (strong, moderate).
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This Committee Opinion has been prepared by the Genetics Committee, reviewed by the Reproductive Endocrinology and Infertility Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

The literature searches and bibliographic support for this guideline were undertaken by Becky Skidmore, Medical Research Analyst, Society of Obstetricians and Gynaecologists of Canada.

Disclosure statements have been received from all members of the committee.

This document reflects emerging clinical and scientific advances on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC.

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SOGC COMMITTEE OPINIONDelayed Child-Bearing

Abstract

Objective

Options

Outcomes

Evidence

Values

Sponsor

Recommendations

Sex Reprod Menopause

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Reprod Biomed Online

Fertil Steril

Genet Med

J Obstet Gynaecol Can

Obstet Gynecol

Fertil Steril

Fertil Steril

BJOG

Obstet Gynecol

Obstet Gynecol

Obstet Gynecol

Am J Obstet Gynecol

Early Hum Dev

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol

Royal College of Obstetricians and Gynaecologists

RCOG statement on later maternal age

Can assisted reproductive technology compensate for the natural decline in fertility with age? A model assessment

Hum Reprod

Maternal age-specific rates of numerical chromosome abnormalities with special reference to trisomy

Hum Genet

Maternal age and fetal loss: population based register linkage study

BMJ

Impact of maternal age on obstetric outcome

Obstet Gynecol

The incidence of ectopic pregnancy in Hordaland County, Norway 1976-1993

Acta Obstet Gynecol Scand

Motherhood at or beyond the edge of reproductive age

In J Fertil Womens Med

Effect of advanced age on fertility and pregnancy in women. 2009.

Changes in maternal characteristics in Nova Scotia, Canada from 1988 to 2001

Can J Public Health

Factors influencing childbearing decisions and knowledge of perinatal risks among Canadian men and women

Matern Child Health J

Fertility and aging: do reproductive-aged Canadian women know what they need to know?

Fertil Steril

Committee on Gynecologic Practice of American College of Obstetricians and Gynecologists; Practice Committee of American Society for Reproductive Medicine. Age-related fertility decline: a committee opinion

Fertil Steril

Accelerated disappearance of ovarian follicles in mid-life: implications for forecasting menopause

Hum Reprod

Age and infertility

Science

Changes with age in the first level and duration of fertility in the menstrual cycle

Hum Reprod

Maternal aging and chromosomal abnormalities: new data drawn from in vitro unfertilized human oocytes, Hum Genet

Management of infertility and pregnancy in women of advanced age. UpToDate 2009

Ageing and infertility: an overview

Gynecol Endocrinol

Reversing the natural decline in human fertility. An extended clinical trial of oocyte donation to women of advanced reproductive age

JAMA

Cumulative conception and live birth rates after oocyte donation: implications regarding endometrial receptivity

Hum Reprod

SOGC COMMITTEE OPINION
Delayed Child-Bearing