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Pregnancy After Age 35
Pregnancy After Age 35 M
ary Newman and Cecile Graf did an excellent job articulating the issues and risks for the “elderly gravida” in their article “Pregnancy After Age 35” (Lifelines, November/ December 2003). However, they omitted an important contributor to gestational risk for this age group— multiple pregnancy. In 2002, the U.S. twin birth rate reached its highest in history, according to the National Center for Health Statistics (Martin et al., 2003). The largest increases in twin births have been among “older” mothers. Between 1990 and 2001, the twin birth rate for women ages 40 to 44 almost doubled, rising from 24.7 to 48.1 per 1,000, and increased another 10 percent from 2001 to 2002 for women over 40. The rate for women ages 45 to 49 has climbed more than eight times,
from 23.8 in 1990 to 189.7 per 1,000 in 2002. Triplet and other higher order multiple births demonstrate similar trends. All data are from CDC/National Center for Health Statistics (2003). The increases in multiple births over the last two decades, especially for triplet and other higher order multiple births, are associated with two related trends: • advances in, and greater access to, fertility therapies and assisted reproductive technologies (ART) • childbearing at an older age, as women 35 years and older are more likely to conceive multiples with or without the use of fertility treatments In their article, the authors detailed the physical and psychosocial risks for women over age 35. It should be noted
Maternal Age
Twin Birth Rate
Higher Order Multiple Birth Rate
25-29 30-34 35-39 40-44 45-54
29/1000 38.9/1000 47.7/1000 52.5/1000 199/1000
152.9/100,000 297.7/100,000 406/100,000 393.6/100,000 2132.3/100,000
(All data from CDC/National Center for Health Statistics, 2003)
April | May 2004
that these risks and complications are compounded by multiple gestation; the higher the fetal number, the greater the risk of poor perinatal outcome. Preterm birth and low birth weight are significant risks, affecting more than 55 percent of twin pregnancies and more than 95 percent of higher order gestations. ART appears to have a negative impact on length of gestation as well. The incidence of hypertension is also related to fetal number (Newman & Luke, 2000): • • • •
7 percent for singletons 14 percent for twins 21 percent for triplets 40 percent for quadruplets
In addition to the inherent maternal age-related risk, genetic disorders and chromosomal abnormalities are more common in multiple gestation. Women ages 30 and older with twins have approximately the same risk of aneuploidy as a woman two years older who is pregnant with a singleton. Psychosocial complications, such as depression and anxiety disorders, are more common with multiple gestation, with increased risk lasting as long as the first two postpartum years. We encourage nurses to learn more about the impact of multiple pregnan-
AWHONN Lifelines
99
cy for all women. A revised edition of the “March of Dimes Nursing Education Module” is slated for release in 2004. The module presents in-depth information regarding pregnancy, birth and neonatal nursing care of multiple-birth families. As coauthors, we believe the module will be useful to nurses across the perinatal care continuum. Nancy A. Bowers, RN, BSN President, Marvelous Multiples, Inc. Karen Kerkhoff Gromada, MSN, RN, IBCLC References: Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Munson, M. L. (2003). Births: Final data for 2002. National Vital Statistics Reports, 52(10). Newman, R. B., & Luke, B. (2000). Multifetal pregnancy. Philadelphia, PA: Lippincott Williams & Wilkins.
NIH Endorses New Cardiovascular Guidelines for Disease Prevention in Women he National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health endorses the evidence-based guidelines for the prevention of cardiovascular disease (CVD) in women released by the American Heart Association. These guidelines promise to improve and enhance efforts to reduce the terrible burden of cardiovascular disease among women. Although there have been tremendous improvements in the prevention and treatment of CVD, it remains the top killer of women, as well as men, in the U.S. Thus, efforts to attack cardiovascular disease through prevention strategies are vitally important. The guidelines support these efforts by giving health care providers a document that assembles in one place the
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100
AWHONN Lifelines
evidence-based recommendations from the NHLBI and other authoritative scientific sources and new recommendations where appropriate. The document thus provides guidance on the best cardiovascular disease preventive care for women with a broad range of cardiovascular risk. The American Heart Association guidelines incorporate and support guidelines developed by the National Cholesterol Education Program, the National High Blood Pressure Education Program, and the Obesity Education Initiative, programs administered by the NHLBI. The document groups women into categories of high, intermediate, and lower risk, allowing physicians and other health care providers to match the intensity of risk intervention to the level of CVD risk. Recommendations range from lifestyle interventions such as following a heart-healthy diet and incorporating physical activity to the use of specific drugs required to treat risk factors for CVD. But none of these interventions can occur if women do not realize that they are at risk for heart disease. As the new survey released by the American Heart Association shows, women have made gains in their awareness of heart disease. In 2003, 46 percent of women surveyed listed heart disease as women’s leading cause of death, better than the 34 percent in 2000 but still short of full awareness. It’s also good news that 90 to 100 percent of women recognized that exercise, losing weight, quitting smoking, making dietary choices that reduce cholesterol levels and reducing salt intake are useful lifestyle changes. We’re pleased to see these improvements, and they show that public awareness and education campaigns like NHLBI’s “Heart Truth” are beginning to have an impact. “The Heart Truth” is primarily targeted to women ages 40 to 60, the time when a woman’s risk of heart disease begins to
increase. The Heart Truth’s Red Dress is the national symbol for women and heart disease awareness and serves as an urgent reminder to every woman to take care of her heart. February 6 is National Wear Red Day. This awareness day, designated in a presidential proclamation, provides women and men across the country a way to be a part of this national Heart Truth awareness movement. The Heart Truth doesn’t stop on February 6. As the survey showed, fewer than half of all women consider themselves very well informed or well informed about heart disease, a figure that The Heart Truth hopes to change. For additional information, visit www.hearttruth.gov. Barbara Alving, MD Acting Director, National Heart, Lung and Blood Institute
NCSBN Responds to Case of Nurse Who Admitted to Killing Patients
T
he National Council of State Boards of Nursing (NCSBN) is dismayed by the recent tragic events surrounding the Charles Cullen case, a nurse who admitted to killing patients while on duty. The vast majority of licensed nurses are highly respected professionals, truly worthy of the public’s trust and accolades. Regrettably, it’s the tragedies invoked by this case that lead us to examine the important work of nurse regulators in protecting the public. Nursing regulation is the governmental oversight of nursing practice, carried out by the 60 state and territorial boards of nursing. Nursing is a regulated profession because of the potential for harm if practiced by someone who is unprepared or incompetent. Boards of nursing protect the public by:
Volume 8
Issue 2
ary Newman and Cecile Graf did an excellent job articulating the issues and risks for the “elderly gravida” in their article “Pregnancy After Age 35” (Lifelines, November/ December 2003). However, they omitted an important contributor to gestational risk for this age group— multiple pregnancy. In 2002, the U.S. twin birth rate reached its highest in history, according to the National Center for Health Statistics (Martin et al., 2003). The largest increases in twin births have been among “older” mothers. Between 1990 and 2001, the twin birth rate for women ages 40 to 44 almost doubled, rising from 24.7 to 48.1 per 1,000, and increased another 10 percent from 2001 to 2002 for women over 40. The rate for women ages 45 to 49 has climbed more than eight times,
from 23.8 in 1990 to 189.7 per 1,000 in 2002. Triplet and other higher order multiple births demonstrate similar trends. All data are from CDC/National Center for Health Statistics (2003). The increases in multiple births over the last two decades, especially for triplet and other higher order multiple births, are associated with two related trends: • advances in, and greater access to, fertility therapies and assisted reproductive technologies (ART) • childbearing at an older age, as women 35 years and older are more likely to conceive multiples with or without the use of fertility treatments In their article, the authors detailed the physical and psychosocial risks for women over age 35. It should be noted
Maternal Age
Twin Birth Rate
Higher Order Multiple Birth Rate
25-29 30-34 35-39 40-44 45-54
29/1000 38.9/1000 47.7/1000 52.5/1000 199/1000
152.9/100,000 297.7/100,000 406/100,000 393.6/100,000 2132.3/100,000
(All data from CDC/National Center for Health Statistics, 2003)
April | May 2004
that these risks and complications are compounded by multiple gestation; the higher the fetal number, the greater the risk of poor perinatal outcome. Preterm birth and low birth weight are significant risks, affecting more than 55 percent of twin pregnancies and more than 95 percent of higher order gestations. ART appears to have a negative impact on length of gestation as well. The incidence of hypertension is also related to fetal number (Newman & Luke, 2000): • • • •
7 percent for singletons 14 percent for twins 21 percent for triplets 40 percent for quadruplets
In addition to the inherent maternal age-related risk, genetic disorders and chromosomal abnormalities are more common in multiple gestation. Women ages 30 and older with twins have approximately the same risk of aneuploidy as a woman two years older who is pregnant with a singleton. Psychosocial complications, such as depression and anxiety disorders, are more common with multiple gestation, with increased risk lasting as long as the first two postpartum years. We encourage nurses to learn more about the impact of multiple pregnan-
AWHONN Lifelines
99
cy for all women. A revised edition of the “March of Dimes Nursing Education Module” is slated for release in 2004. The module presents in-depth information regarding pregnancy, birth and neonatal nursing care of multiple-birth families. As coauthors, we believe the module will be useful to nurses across the perinatal care continuum. Nancy A. Bowers, RN, BSN President, Marvelous Multiples, Inc. Karen Kerkhoff Gromada, MSN, RN, IBCLC References: Martin, J. A., Hamilton, B. E., Sutton, P. D., Ventura, S. J., Menacker, F., & Munson, M. L. (2003). Births: Final data for 2002. National Vital Statistics Reports, 52(10). Newman, R. B., & Luke, B. (2000). Multifetal pregnancy. Philadelphia, PA: Lippincott Williams & Wilkins.
NIH Endorses New Cardiovascular Guidelines for Disease Prevention in Women he National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health endorses the evidence-based guidelines for the prevention of cardiovascular disease (CVD) in women released by the American Heart Association. These guidelines promise to improve and enhance efforts to reduce the terrible burden of cardiovascular disease among women. Although there have been tremendous improvements in the prevention and treatment of CVD, it remains the top killer of women, as well as men, in the U.S. Thus, efforts to attack cardiovascular disease through prevention strategies are vitally important. The guidelines support these efforts by giving health care providers a document that assembles in one place the
T
100
AWHONN Lifelines
evidence-based recommendations from the NHLBI and other authoritative scientific sources and new recommendations where appropriate. The document thus provides guidance on the best cardiovascular disease preventive care for women with a broad range of cardiovascular risk. The American Heart Association guidelines incorporate and support guidelines developed by the National Cholesterol Education Program, the National High Blood Pressure Education Program, and the Obesity Education Initiative, programs administered by the NHLBI. The document groups women into categories of high, intermediate, and lower risk, allowing physicians and other health care providers to match the intensity of risk intervention to the level of CVD risk. Recommendations range from lifestyle interventions such as following a heart-healthy diet and incorporating physical activity to the use of specific drugs required to treat risk factors for CVD. But none of these interventions can occur if women do not realize that they are at risk for heart disease. As the new survey released by the American Heart Association shows, women have made gains in their awareness of heart disease. In 2003, 46 percent of women surveyed listed heart disease as women’s leading cause of death, better than the 34 percent in 2000 but still short of full awareness. It’s also good news that 90 to 100 percent of women recognized that exercise, losing weight, quitting smoking, making dietary choices that reduce cholesterol levels and reducing salt intake are useful lifestyle changes. We’re pleased to see these improvements, and they show that public awareness and education campaigns like NHLBI’s “Heart Truth” are beginning to have an impact. “The Heart Truth” is primarily targeted to women ages 40 to 60, the time when a woman’s risk of heart disease begins to
increase. The Heart Truth’s Red Dress is the national symbol for women and heart disease awareness and serves as an urgent reminder to every woman to take care of her heart. February 6 is National Wear Red Day. This awareness day, designated in a presidential proclamation, provides women and men across the country a way to be a part of this national Heart Truth awareness movement. The Heart Truth doesn’t stop on February 6. As the survey showed, fewer than half of all women consider themselves very well informed or well informed about heart disease, a figure that The Heart Truth hopes to change. For additional information, visit www.hearttruth.gov. Barbara Alving, MD Acting Director, National Heart, Lung and Blood Institute
NCSBN Responds to Case of Nurse Who Admitted to Killing Patients
T
he National Council of State Boards of Nursing (NCSBN) is dismayed by the recent tragic events surrounding the Charles Cullen case, a nurse who admitted to killing patients while on duty. The vast majority of licensed nurses are highly respected professionals, truly worthy of the public’s trust and accolades. Regrettably, it’s the tragedies invoked by this case that lead us to examine the important work of nurse regulators in protecting the public. Nursing regulation is the governmental oversight of nursing practice, carried out by the 60 state and territorial boards of nursing. Nursing is a regulated profession because of the potential for harm if practiced by someone who is unprepared or incompetent. Boards of nursing protect the public by:
Volume 8
Issue 2