This chapter examines the risks of pregnancy for women over 40 and the strategies to optimize the management of pregnancy, labour and puerperium in this age group. In the UK, antenatal care is not usually any different at less than 40 years unless there are other confounding factors. Women at advanced age booking for pregnancy should have a thorough risk assessment to ascertain risk of hypertensive diseases of pregnancy and those at higher risk should be started on 75 mcg aspirin from 12 weeks till until 36 weeks Increased surveillance for GDM is not recommended in the UK based on age alone. However, it should be noted that AMA is associated with an increased background incidence of diabetes and it is our practice to offer a mini glucose tolerance test. Risk of venous thromboembolism should be assessed at booking and at each encounter. Serial growth scans with doppler studies are to be performed starting from 26-28 weeks of gestation in women more than 40 years. Induction of labour is recommended between 39 to 40 weeks when maternal age is more than 40 years. There is insufficient evidence to comment on the possible effect on perinatal mortality and rates of operative delivery from this intervention and this should be mentioned when counselling for induction of labour.

Key Learning Points

1. 1. The critical care population is at high risk of venous thromboembolism.

2. 2. Classification of pulmonary embolism is based on mortality risk.

3. 3. The clinical presentation of pulmonary embolism in the critical care environment is atypical and diagnosis remains difficult.

4. 4. Computed tomography pulmonary angiography is the investigation of choice for pulmonary embolism.

5. 5. Anticoagulation is the mainstay of acute treatment, with thrombolysis being reserved for high-risk pulmonary embolism.

Successful anticoagulation is a fine balance between clotting and bleeding, which can easily go wrong. The good news is that basic principles can help manage this scenario effectively. The author provides background information on low molecular weight heparins, their use in the treatment and prevention of deep vein thrombosis and pulmonary embolism, its monitoring and reversal, and dose adjustment for body weight and renal function.