Advanced maternal age and ART singleton — structured SAQ (15 marks)

(a) Three independent risk contributions (3 marks)

One mark per contribution with a brief explanation. ^[5][6]

• Age (41 years — very advanced maternal age) — higher aneuploidy, gestational diabetes, preeclampsia, stillbirth and caesarean; the risks rise exponentially from the mid-thirties.
• Subfertility (seven years primary infertility) — subfertility itself is an independent risk factor for adverse outcomes, including preeclampsia, preterm birth and perinatal mortality, independent of ART.^[5]
• ART (ICSI conception) — IVF/ICSI singleton pregnancies carry excess risk of preterm birth, low birthweight, small-for-gestational-age, hypertensive disorders and perinatal mortality compared with spontaneous conceptions (Pandey 2012).^[3]
• Plus BMI 31 (a fourth, bonus factor) — a moderate preeclampsia risk factor in its own right.

(b) Surveillance plan for preeclampsia and fetal growth (5 marks)

One mark per element, maximum five. ^[3][7]

• Low-dose aspirin from 12 weeks to 36 weeks — she has multiple preeclampsia risk factors (nulliparity, age 35 or older, ART-conceived pregnancy, BMI over 30), so low-dose aspirin is clearly indicated, dosed per local guideline.^[7]
• Uterine artery Doppler in mid-gestation — to stratify risk; normal Dopplers reduce the predicted preeclampsia risk.
• Serial growth scans through the third trimester — the ART singleton excess risk of small-for-gestational-age and preterm birth warrants this; umbilical artery Doppler if growth-restricted.^[3]
• Gestational diabetes screening — early glycaemic assessment given her age and BMI, with formal testing in mid-pregnancy.
• Blood pressure monitoring at every visit with a low threshold for investigation of symptoms and heightened surveillance for the older mother.

(c) Counselling on congenital anomalies and imprinting disorders (4 marks)

One mark per point, maximum four. ^[2][4]

• Congenital anomalies are modestly increased in ART singletons. The Davies 2012 NEJM study found an adjusted odds ratio of 1.28 for any birth defect with assisted conception overall; the ICSI signal persisted after adjustment (adjusted OR 1.57), although residual confounding cannot be excluded. A history of infertility was also associated.^[2]
• Imprinting disorders are increased but the absolute risk is small. The Lazaraviciute 2014 meta-analysis found a combined odds ratio of 3.67 (95% CI 1.39 to 9.74) for any imprinting disorder in IVF/ICSI children compared with spontaneous conception.^[4]
• The clinically recognised syndromes are Beckwith-Wiedemann (macrosomia, lateralised overgrowth, abdominal wall defects, neonatal hypoglycaemia) and Angelman syndrome (severe developmental delay, seizures, ataxia), with weaker signals for Russell-Silver.
• Counselling principle: a small absolute increase on a rare baseline. Do not overstate; do not ignore. The large majority of ICSI children are healthy.

(d) Timing and mode of birth at 39 weeks (3 marks)

One mark per element, maximum three. ^[1]

• Quote the Reddy 2006 stillbirth data: at 37 to 41 weeks, the risk of stillbirth is about 1 in 382 ongoing pregnancies for ages 35 to 39 and about 1 in 267 for age 40 or older — roughly 99.6% of ongoing term pregnancies in women over 40 end in a live birth.^[1]
• There is no evidence for routine early induction in advanced maternal age alone — the decision to offer induction at 39 to 40 weeks is shared, weighing the stillbirth risk against the iatrogenic prematurity and caesarean risks of induction.
• Mode of birth is for obstetric indications — caesarean is not mandated by age or ART alone; offer a vaginal birth with a clear plan for monitoring and escalation. Counsel honestly about the higher caesarean rate in older ART mothers and the reasons for it.