Can a 45-year-old female with potential underlying medical conditions, such as hypertension (high blood pressure) or diabetes, and advanced maternal age, still become pregnant?

Can a 45-Year-Old Woman Get Pregnant?

Yes, pregnancy is biologically possible at age 45, but fertility is severely diminished with only 1-2% chance of conception per cycle using her own eggs, and the risks to both mother and baby are substantially elevated. 1, 2

Natural Fertility at Age 45

• Fecundity declines dramatically after age 37, with women aged 45 or older experiencing approximately a 50% decrease in fertility compared to younger women. 3, 1
• In IVF studies, clinical pregnancy rates drop to 1.9% at age 44, and no pregnancies resulted from 54 IVF cycles in women aged 45 or older using their own eggs. 2
• Women over 40 should receive immediate evaluation and treatment rather than waiting 6 months of failed conception attempts, as recommended for younger women. 1

Pregnancy Risks with Underlying Conditions

Hypertension Management

• Women with chronic hypertension face a 25% risk of developing superimposed preeclampsia during pregnancy, with outcomes directly related to blood pressure control. 4
• Blood pressure must be controlled below 140/90 mmHg before conception using pregnancy-safe medications (extended-release nifedipine, labetalol, or methyldopa). 5, 4
• ACE inhibitors and ARBs are absolutely contraindicated and must be discontinued before attempting conception due to fetal teratogenicity and oligohydramnios. 5, 4
• Target blood pressure during pregnancy should be 110-135/85 mmHg to minimize both maternal complications and impaired fetal growth. 6, 5

Diabetes Risk

• Women over 40 have approximately 2.8 times higher risk of developing gestational diabetes, requiring earlier screening than the standard 24-28 weeks. 6
• HbA1c should be less than 6.5% before conception, and ideally less than 6% if achievable without hypoglycemia. 5
• Women with history of gestational diabetes require fasting glucose and 2-hour 75g OGTT to rule out progression to type 2 diabetes before attempting pregnancy. 5

Maternal Complications at Age 45

• Gestational diabetes occurs in 12.7% and preeclampsia in 10.1% of pregnancies in women 45 or older. 7
• The cesarean section rate is 31.7-50% in this age group, significantly higher than younger women. 7
• Women aged 41 years and older with multiple chronic conditions are more likely to experience severe maternal morbidity or mortality than younger women. 8
• Women over 40 have 2-3 times higher risk of developing preeclampsia and gestational hypertension, requiring regular blood pressure monitoring at each prenatal visit. 6

Fetal and Pregnancy Complications

• Spontaneous abortion rates are 2-3 fold higher in women over 40, with approximately 30-50% of pregnancies ending in miscarriage. 3, 9
• Chromosomal abnormalities occur in approximately 10% of pregnancies at age 45 or older. 7
• Increased risks include preterm birth (15.2%), low birth weight (17.3%), macrosomia (19.8%), and stillbirth. 3, 7
• The corrected perinatal mortality rate is 1.3% in women over 45. 7

Essential Preconception Interventions

Immediate Actions Required

• Low-dose aspirin (75-150 mg daily) at bedtime should be started immediately, either pre-pregnancy or upon pregnancy confirmation but before 16 weeks gestation, to reduce preeclampsia risk. 5, 4
• Folic acid 400 mcg daily should be initiated for neural tube defect prevention. 8, 5
• Comprehensive genetic screening and counseling regarding non-invasive prenatal testing, chorionic villus sampling, or amniocentesis should be offered due to elevated chromosomal abnormality risk. 6

Required Baseline Testing

• Complete blood count, liver enzymes, serum creatinine, electrolytes, uric acid, and urine protein-to-creatinine ratio or 24-hour urine protein to establish baseline for detecting superimposed preeclampsia. 6, 5
• Comprehensive ophthalmologic exam to assess for hypertensive or diabetic retinopathy. 5
• ECG given age over 35 years with cardiac risk factors. 5

Contraception Until Optimization

• Copper IUD is the optimal contraceptive choice with less than 1% failure rate and no hormonal effects on blood pressure or glucose metabolism. 5
• Combined hormonal contraceptives are absolutely contraindicated in women with systolic BP ≥140 mmHg or diastolic ≥90 mmHg, as ischemic stroke risk increases 8-15 fold. 5

Alternative Reproductive Options

• Egg donation offers delivery rates close to 50% in women over 40, representing a significantly more successful alternative to using own eggs. 2
• Given the marked decline in success rates, IVF treatment using own eggs should be limited to patients not older than 43 years with adequate ovarian response. 2

Long-Term Cardiovascular Implications

• Women experiencing adverse pregnancy outcomes have early manifestations of vascular changes, with endothelial dysfunction persisting beyond pregnancy complications. 8
• Women with hypertensive disorders of pregnancy have 42% greater risk of cardiovascular disease within the first 5 years after delivery, even after adjusting for other risk factors. 8
• Annual cardiovascular risk assessment is required lifelong after pregnancy with hypertensive disorders, with aggressive management of modifiable risk factors essential. 5

Critical Pitfalls to Avoid

• Failing to discontinue ACE inhibitors/ARBs before conception is the most critical error, as 50% of pregnancies are unplanned and early exposure causes fetal harm. 4
• Continuing lifestyle modification alone at BP ≥150/90 mmHg is inadequate—pharmacological treatment must be initiated immediately. 4
• Delaying evaluation and treatment beyond immediate assessment in women over 40 attempting conception wastes precious time given age-related fertility decline. 1
• Using short-acting nifedipine for maintenance therapy—only extended-release formulations should be used for chronic management. 4