This is a time of huge change, both physical and emotional. While your body starts to create the environment where your baby will grow, you may feel exhausted and emotionally overwhelmed.

Physical Changes

The most significant physical change in the early weeks of pregnancy is persistent tiredness, and although this feeling is by no means unique to women over 35 women who have had pregnancies in their 20s and again in their late 30s agree that the depth of fatigue is greater when older.

Many women also experience daily nausea or hunger pangs. The huge hormonal adjustments in response to pregnancy can also cause emotional turmoil. Being more tired than every one else, and more irritable, introduces new challenges in to your relationships and your career life. During these first months of pregnancy a gentle exercise program can help restore your emotional balance and increase your energy. Your food plan will need to include meals that cover your increased requirements for protein and help you deal with nausea. Now is also the time to find the doctor or midwife who will care for you during the next 9 months and help bring your baby in to the world. Understanding what to expect from your prenatal care will help you know what questions to ask your care provider so you get the answers you need. More screening tests are offered to women over 35 than to their younger counterparts. Becoming informed about tests, the pros and cons of genetic counseling, screening for down syndrome and one of the earliest screening tests for developmental abnormalities, CVS, will help ensure that your experience is a positive one.

Your Baby’s Development

Your baby creates a life sustaining connection with you, through the placenta. All of the major organs form during this time including your baby’s heart, spine and kidneys. Your baby’s heart will start to beat and the heartbeat can be seen on ultrasound by 6 weeks after your last period. Your baby’s arms and legs will form and your baby will start to move, although it is too early for you to feel it.

Althought your pregnancy won’t be considered high risk just because you are over 35, your age does mean that you might be more likely to have or to develop a problem that results in extra monitoring, tests or treatment. Some conditions develop during your pregnancy, others conditions, such as high blood pressure, make your pregnancy high risk from the start.

Gestational Diabetes

Gestational diabetes is a disorder of sugar (glucose) regulation that occurs specifically in pregnancy. It means that your body’s ability to regulate your sugar levels is not up to the strain of pregnancy.

Normally, sugar levels are regulated by a balance between two hormones insulin (produced in your pancreas) and glucagon (made by your liver). Insulin is released when your blood sugar levels rise after eating, allowing your body to remove excess sugar from your bloodstream. Glucagon is released when your blood sugar levels are low, triggering a rise in your blood sugar levels.

Diabetes And Labor

Women with gestational diabetes requiring treatment are at increased risk of having a large baby the risk depends partly on how well blood sugars are controlled during your pregnancy. If you have diabetes, your doctor will usually estimate your baby’s birth weight before you go into labor, either by feeling your baby through the uterus or using ultrasound. If your baby is normal size, your physician may induce labor at 39 weeks because of the increased risk of fetal complications in prolonged pregnancy in women with diabetes. During labor you will need to have an IV and your blood sugars will be carefully monitored every hour or two. If your baby weighs more than 9-9½1b (4 to 4.5kg) there is a risk that the shoulders may get stuck (known as shoulder dystocia), which increases the chance of a birth injury or other serious complications. Your physician will talk to you about this risk and may offer you a cesarean delivery.

Type Of Diabetes

In gestational diabetes, your body either fails to produce enough insulin to cope with the strain of pregnancy or your body’s cells are resistant to insulin’s action. This is similar to type 2 diabetes (sometimes called adult onset diabetes). Type 1 diabetes, which usually begins in childhood or adolescence is different in that the pancreas doesn’t make any insulin. During pregnancy, your placenta produces a hormone called human placental lactogen (HPL), which makes your blood sugar levels rise. As a result of this, your body has to produce more insulin to maintain normal sugar levels. Gestational diabetes will disappear after your pregnancy is over, but you are much more likely to develop type 2 diabetes later.

How Is It Diagnosed?

Gestational diabetes is initially detected in the third trimester of pregnancy by a one-hour glucose test a screening test to identify women at a higher risk of sugar problems. Women who are found to be at risk then haw diagnostic test called a glucose tolerance test to determine whether or not they have gestational diabetes. This test is very similar to the one-hour test, but you have to get your blood drawn four times instead of just once. Blood glucose levels are checked when you haven’t eaten anything (fasting), then 1, 2, and 3 hours after you drink a second sugar drink. If your blood sugar levels are high after your 3 hour glucose test, it means your body was not able to handle a sugar load and you have gestational diabetes. Different care providers may use slightly different sets of criteria to diagnose gestational diabetes based on your blood test. Some doctors may consider a particular glucose tolerance test result borderline, while others will want to monitor and treat you actively.

Cervical Insufficiency

This is an uncommon condition, sometimes known as cervical incompetence, where the cervix opens (dilates) without you having contractions. Cervical insufficiency can be a cause of miscarriage in the second trimester. If you have miscarried in the second trimester in the past .with out having painful contractions your care provider may recommend you have a cerclage in this pregnancy. A cerclage is a stitch that is placed around the cervix to keep it tightly closed, rather like a drawstring around the neck of a balloon. An alternative to a cerclage, in some cases, is for you to be monitored with a transvaginal ultrasound weekly or every other.

How Is It Treated?

In most cases, gestational diabetes can be treated by adjusting your diet to reduce your carbohydrate in take. Your care provider may suggest you see a nutritionist, who will advise you on what you can and cannot eat. You are likely to be told to eat unrefined, complex carbohydrales such as wholemeal bread, rice and pasta and to avoid cakes, sodas, and sweets. Your care provider will monitor your blood sugar on your new diet. Your blood sugar may have to be tested up to four times a day at home, and you will be expected to do this testing yourself using a simple, handheld glucose monitor. If your blood sugars remain high, you will need to have insulin injections (twice a day injection) or possibly a glucose-lowering pill.

Future Risk Of Diabetes

If you develop gestational diabetes during your pregnancy you are more likely to develop type 2 diabetes later in life. You should be tested for diabetes with a blood test (after another glucose drink) 6 weeks after your pregnancy, and then at regular intervals after that. week. A small ultrasound probe is inserted in the vagina and the cervix is imaged on a screen.

If your cervix shows signs of opening up, your care provider may recommend you have a cerclage at that point. Sometimes changes in your cervix are noted during a routine, second trimester ultrasound. In this case, if you’ve not had a miscarriage before, it is controversial whether placing a cerclage is helpful. Your care provider will review the risks and benefits with you or refer you to a specialist for consultation.

For women who want information about the risk of down syndrome but who wish to avoid moving directly to an invasive test such as chorionic villus sampling or amniocentesis, first trimester testing offers an early screening option, although it cannot give a definitive result.

First trimester screening is performed between 11 and 14 weeks of pregnancy and uses a combination of a blood test and an ultrasound to determine the risk of your baby being born with down syndrome or some other chromosomal abnormality. The ultrasound measures the thickness of the skin at the back of your baby’s neck, called the nuchal fold, which is thicker in babies with down syndrome. On the same day as the scan, you will have blood drawn and tested for levels of pregnancy associated plasma protein A (PAPP-A) and human chorionic gonadotropin (hCG). Using the combined results of blood tests, age, and nuchal translucency measurement, the doctor will be able to calculate your baby’s risk of down syndrome. You will receive the results a few days after the test. Your risk will be compared with what the risk of chromosomal abnormality would be for a woman of your age. Your new risk may be higher, lower, or the same as your risk based on your age alone. The test is called positive if your risk of having a baby with down syndrome is higher than a preset cutoff point, usually 1 in 250. A positive test does not mean that your baby has down syndrome, only that the risk is greater. First trimester screening will also detect most babies affected by trisomy18.

Test Accuracy

In women over the age of 35, first trimester screening will detect 85 to 95 percent of babies with down syndrome. However, it can also give a false negative result (suggesting the baby is at low risk down syndrome when in fact the baby is affected). First trimester screening will be negative in between 5 and 15 percent of pregnancies where the baby has down syndrome.

How Age Affects Results

The test is more likely to come back positive as you get older. In women over the age of 35, a quarter of tests will be positive. Although most of these mothers will still have a normal baby, their results may make CVS or amniocentesis a reasonable option. However, 75 percent of women will have a negative test and can feel more comfortable about avoiding CVS or amniocentesis.

Results

If your test is positive

Even with a positive result. the chance of your baby having down syndrome is still very small You will be told the actual statistical risk of your baby having down syndrome; you can compare this risk to the risk of miscarriage with CVS or amniocentesis. Only one of these tests can give you a definitive answer.

If your test is negative

If your first trimester screening test is negative, then your baby has a very, very low chance of having down syndrome. However, if you are still nervous after the screening test, you can have either CVS or amniocentesis. Both of these tests will give you a definitive result.

Nuchal Translucency Scan

• The test is usually performed at 11-14 weeks of pregnancy. The doctor or technician (sonographer) performing the scan will place the ultrasound probe on your belly and look for an area at the back of the baby’s neck called the nuchal translucency. The person doing the scan will mark two points and take a measurement of the thickness at this point. If the measurement is small, the risk of down syndrome is low (the exact measurement depends on the size of the baby). A larger thickness at this point generally indicates that there is a higher than normal risk of the baby having down syndrome.
• Normal nuchal scan shows the outline of the baby, two crosses marking the back of the neck. A narrow gap suggests a low risk of down syndrome. The nuchal translucency scan result must be combined with the results of your blood tests to accurately assess your baby’s risk of down syndrome.
• Abnormal scan shows a thickening at the back of the neck (marked with two crosses). The greater the thickness, the higher the (risk of down syndrome. This test is very dependent on the skill of the sonographer. A poor ultrasound can miss down syndrome or give a positive result with a normal baby.

The signals that cause labor to start are not well understood, but signs from your baby that indicate to your uterus that he or she is ready to be born are probably involved. Once your uterus is is ready to go in to labor, many other signals can stimulate contractions. However, if your body is not ready, things you try to start labor may only cause an increase in mild contractions.

Home Strategies

Probably the most enjoyable way to bring on labor is to make love with your partner. Human sperm contains natural prostaglandin’s that are a great stimulant to the uterus. Having sex is not harmful to your baby unless your doctor has specifically told you to refrain from intercourse for a medical reason. Stimulating your nipples either

during sex or by it self can also cause the release of the oxytocin, a hormone that causes the uterus to contract and the cervix to ripen. This works best if the nipples are rolled between the thumb and forefinger for about 20 minutes. It’s safe to do this several times a day. Other less effective methods of bringing on labor include walking and other exercise that may cause a mild increase in uterine contractions, but are safe to try.

Herbal Remedies

These remedies, are best avoided some are potentially harmful, and the level of active ingredients with in herbal. preparations varies widely, so it is difficult to know how much medication you and your baby are getting. Many powerful drugs that we currently use were originally purified from plants, and so called natural preparations can still contain potent medications with side effects that can be every bit as serious as drugs you buy from a pharmacy. In the end, you must balance your beliefs against the scientific unknowns that surround herbal medicine. Castor oil and enemas are not particularly effective for bringing on labor and can dehydrate you.

Medical Induction

It is not surprising that many women beg to be induced once they approach their due date or even before. After discussing your reasons with your care provider, choosing labor induction is an option, but there are risks. It is not recommended if you have previously had a cesarean.

Risks of induced Labor

Induced labor is less effective than spontaneous labor, and you are 1.5-2 times more likely to need a cesarean delivery if this is your first baby. Induced labors are also longer than spontaneous labor, and you are likely to spend an extra day or two in the hospital while your cervix is made ready for labor and contractions are induced with drugs.

Methods Of Induction

There are several medical methods for inducing labor.

Stripping The Membranes

This is the least invasive way for your care provider to stimulate labor. To strip or sweep the membranes your provider will do a cervical exam as usual and then run a finger between your cervix and the bag of water. This action stretches the cervix and releases natural substances that may help ripen your cervix and increase contractions. It is common to have vaginal spotting on your underwear afterward, but you do not need to call your care provider unless the bleeding is heavy, you think your water has broken, your baby is not moving frequently, or you go in to labor. The procedure will not increase your chance of a cesarean delivery.

Cervical Ripening

Various medications or devices may be used to soften, thin and dilate the cervix. Once the cervix is dilated, oxytocin is usually given to start contractions. Ripening is usually done with prostaglandins (administered as a suppository or gel) or with a foley catheter. A Foley catheter is a narrow tube with a balloon on its end, which is placed through the cervix while deflated, then inflated at the top of the cervix. Neither of these procedures are more uncomfortable than a regular vaginal exam, but both can result in mild contractions.

Misoprostol

This is a prostaglandin treatment that causes cervical ripening and contractions at the same time. It is usually only given in hospital and won’t be used if you’ve had a cesarean in the past because there is a greater risk of uterine rupture. Misoprostol can be given vaginally or by mouth.

Oxytocin

This is a substance that is naturally released during labor. In cases of induction, synthetic oxytocin is given to make uterine contractions stronger. It can also be used to strengthen contractions once you are in labor. Some people believe oxytocin makes contractions unnaturally strong, but because some of the early painful contractions are strengthened, it may help move you more quickly in to active labor. Most hospitals will want you to have continuous fetal and uterine monitoring to check your baby for signs of stress if you are receiving oxytocin.

Rupture Of Membranes

If you have had a vaginal delivery in the past and your cervical exam is favorable, releasing the amniotic fluid from around your baby may be enough to send you in to labor. Sometimes, membrane rupture is used in combination with oxytocin.

Medical Reasons For Induction

Sometimes the medical balance is in favor of being artificially induced. In these cases, the risk of continued pregnancy to you and your baby outweigh the increased risk of cesarean delivery. Some medical indications for induction include.

• Low levels of amniotic fluid
• Preeclampsia
• Your baby is not growing well (intrauterine growth restriction)
• Prolonged pregnancy past 41-42 weeks (1 to 2 weeks past your due date).