Pregnancy at 40: What Went Through My Mind Deciding to Have My Second Baby
By Dr. Pallavi Kulkarni, MBBS, DGO, DNB (OB-GYN), DFP, MRCOG (UK), Fellowship in IVF
There is a moment I remember from the year I turned 40. My older child had fallen asleep against my shoulder, heavy the way children get when they have finally stopped fighting it, and I was thinking very clearly that I wanted to do this again. It was not a plan yet. It was a sentence in my head that would not leave.
The sentence was the easy part. The next twelve months were not.
Why a second baby, why then
I was 40. Not 40 in the way people say it to be polite - “just turned 40, plenty of time” - but actually, medically, 40. I knew what the fertility curves looked like because I had drawn them on clinic whiteboards for years. I knew the egg quality data. I knew the miscarriage rates by heart. I had told hundreds of women these numbers, calmly, with graphs.
Now I was on the other side of the desk.
There were two voices in my head, and they took turns. The first one said: you are a healthy woman who wants another child. Women have babies at 40 every day. You have access to the best care. Go ahead. The second one said: you know the numbers better than anyone. You know what can go wrong. You know what screening means at this age, and you know what the results might ask you to decide.
The second voice was not louder, but it was more specific. And specificity is what keeps you awake. The miscarriage rate at 40 is roughly 1 in 3. The chance of Down syndrome is about 1 in 100. But that also means 2 out of 3 pregnancies at 40 do not miscarry, and 99 out of 100 babies do not have Down syndrome. The same numbers that scare you can also reassure you, depending on which direction you read them from.
The first scan
The first scan is the one where you hold your breath and pretend you are not holding your breath. I have watched thousands of women do this. I have told them to relax. Now I understood why that is a useless thing to say.
At 40, the ACOG guidelines on pregnancy at age 35 or older recommend first-trimester combined screening between 11 and 14 weeks. This is the nuchal translucency scan combined with blood markers. It gives you a risk estimate - not a diagnosis, a probability. I knew this. I had explained it to patients perhaps a thousand times. But sitting there with the gel on my own abdomen, I understood for the first time that a probability is not a number. It is a feeling. It is the weight of what you would do with a bad one.
The nuchal measurement was normal. The blood markers were reassuring. I exhaled. But the process had started - the process of being screened, of being watched, of being the patient who is also reading the report over the doctor’s shoulder.
The MTP window, which I thought about first
I am going to say something that most doctors will not put in writing: the first thing I thought about, before the joy, before the planning, before telling family - was the MTP timeline.
Under the MTP (Amendment) Act, 2021, termination is permitted up to 20 weeks on a single doctor’s opinion, up to 24 weeks on two doctors’ opinion for specific categories including substantial fetal abnormality, and beyond 24 weeks only through a Medical Board for significant fetal abnormalities.
I thought about this not because I wanted a termination. I thought about it because I am a 40-year-old obstetrician who knows that screening results arrive on a calendar, and that calendar has legal boundaries. If the first-trimester screen had flagged a high risk, I would need NIPT or amniocentesis. If those confirmed a serious abnormality, I would need to make a decision. And that decision has a deadline.
This is not a comfortable paragraph. I would rather write about nursery colours. But I promised myself I would write this honestly, because every 40-year-old woman thinking about pregnancy deserves to know that these timelines exist and that thinking about them is not pessimism. It is planning.
“Thinking about screening timelines and legal windows before you even feel joy is not pessimism. It is what responsible planning at 40 looks like. Every woman in this situation deserves to know that.”
- Dr. Pallavi Kulkarni
If you are pregnant at 40 or considering it, a single consultation can help you understand the screening timeline, what each test tells you, and what your options are at each stage.
Deciding on screening, and going further
After the first-trimester combined screen came back low-risk, I still had to decide whether to do NIPT. Most women at 40 are offered it. Most accept. The ACOG Practice Bulletin on screening for fetal chromosomal abnormalities recommends that all pregnant women, regardless of age, be offered both screening and diagnostic testing. At 40, this is not a gentle suggestion. It is an expectation.
NIPT - non-invasive prenatal testing - analyses fragments of fetal DNA circulating in the mother’s blood. A large meta-analysis by Gil and colleagues found that for Down syndrome, NIPT has a sensitivity above 99 percent. It is very good. Not perfect - it is still a screening test, not a diagnostic one - but very good.
I did the NIPT. It came back low-risk. And then I had to decide whether to do amniocentesis anyway.
Amniocentesis is the definitive test. It takes cells directly from the amniotic fluid and gives you a karyotype - the actual chromosomes. It carries a small additional miscarriage risk, around 0.1 to 0.2 percent above background in experienced hands. That is a real number. It is small, but it is not zero, and when it is your pregnancy the smallness of the number does not help as much as you would think.
I decided not to do amniocentesis. My combined screen was reassuring. My NIPT was reassuring. I had two concordant low-risk results. I could have gone further, but I chose not to, and I made that choice the same way I ask my patients to make it: by thinking about what I would do with the information, and whether the additional certainty was worth the additional risk.
For me, in that pregnancy, it was not. For another woman, in another pregnancy, it might be. That is the point. It is a real choice, not a default.
The autism article a friend sent me
Somewhere around 16 weeks, a well-meaning friend sent me an article about advanced maternal age and autism risk. The article was not wrong, exactly. It was just incomplete in the way that health journalism often is - alarming without context.
Here is the context. A large Swedish study by Sandin and colleagues did find a small association between advancing maternal age and autism spectrum disorder. But the absolute numbers are small, the paternal-age association is actually more consistent in the literature, and the mechanisms are poorly understood. Advanced maternal age is one of dozens of factors studied. It is not a cause in the way that, say, a genetic mutation is a cause.
More importantly: no prenatal test screens for autism. There is no blood draw at 12 weeks that will tell you. There is no scan finding. There is nothing actionable about this information during pregnancy except worry, and worry is not a plan.
And while I am here: vaccines do not cause autism. That has been studied exhaustively and the answer is no. I mention it because the same friend who sent me the maternal-age article later sent me a “natural immunity” post, and I want to be clear about where the evidence stands.
I thanked her for the article. I did not send her the Sandin paper. I probably should have.
The waiting
The part of pregnancy nobody prepares you for is the waiting. Not the medical waiting - the results, the scans, the glucose tolerance test at 24 weeks. I mean the emotional waiting. The space between knowing that the numbers are in your favour and actually believing it.
I walked a lot during those months. Early morning, before clinic, on the road behind our building where nobody is awake yet and the light is still grey. I did not listen to music or podcasts. I just walked. I was not anxious in any clinical sense. I was not losing sleep or catastrophising. I was just aware, in a way I had never been with my first pregnancy, that this one was improbable. Not miraculous - I do not like that word for something that happens to millions of women every year - but statistically less likely. And I was grateful in a way that felt physical, not sentimental.
The anomaly scan at 20 weeks was normal. The growth scans were on track. My blood pressure behaved. The baby moved on schedule, first like bubbles, then like elbows.
I was still a doctor. I still read my own reports before my obstetrician called. But I was learning, slowly, to be a patient first and a doctor second. It did not come naturally.
What my own pregnancy changed in my practice
I had always thought I was empathetic. I listened. I explained. I gave women time. But my own pregnancy after 35 taught me something I could not have learned any other way: that knowing the statistics and living inside them are entirely different experiences.
When a woman sits across from me now and asks “but is my baby going to be okay?” I no longer hear a medical question. I hear the question underneath it, the one she cannot say out loud: am I going to survive this emotionally if something goes wrong?
I answer differently now. I still give the numbers. I still explain the screening options. But I also say, plainly: “I understand what you are feeling because I have felt it. The uncertainty is real, and it does not go away just because the numbers are good.”
That sentence is not in any textbook. But it is the one that makes women exhale.
“I understand what you are feeling because I have felt it. The uncertainty is real, and it does not go away just because the numbers are good. Knowing the statistics and living inside them are entirely different experiences.”
- Dr. Pallavi Kulkarni
I also became more honest about what high-risk pregnancy care actually involves. It is not drama. It is not emergencies. Most of the time it is monitoring - more scans, more blood tests, more visits - and the emotional toll of that monitoring on a woman who just wants to be told everything is fine.
The birth, and a short reflection
The birth was uncomplicated. I will spare you the details because they belong to my family, not to the internet. But I will say this: the moment they put my second child on my chest, what I felt was not what I expected. It was not the overwhelming flood people describe. It was quieter. It was the feeling of a long, careful calculation finally resolving into something that did not need calculating at all.
I had spent a year weighing risks, reading studies, tracking numbers. And then there was a baby, and the numbers stopped mattering.
This is not a medical insight. It is a personal one. But I think it matters because it is the thing I could never have explained to a patient before I lived it. The difference between recommending and deciding. Between interpreting a risk table and being a row in one.
“I had spent a year weighing risks, reading studies, tracking numbers. And then there was a baby, and the numbers stopped mattering. The difference between recommending and deciding - between interpreting a risk table and being a row in one - is something I could never have explained before I lived it.”
- Dr. Pallavi Kulkarni
If you are at the edge of your own decision
If you are reading this at 38 or 40 or 42, turning the idea of a baby over in your head, here is what I would tell you as both a doctor and a mother who has been there.
The risks are real but they are manageable. According to ACOG data, the risk of gestational diabetes at 40 is roughly twice that of a woman in her twenties, and preeclampsia rates increase modestly. But these are monitored conditions, not unmanageable ones. Pregnancy after 35 is not what it was a generation ago. We have better screening, better monitoring, and a much clearer understanding of what “advanced maternal age” actually means in clinical terms. It means closer attention, not a warning label.
Get your baseline tests done. Understand your fertility picture. Book early. See someone who will be honest with you about the numbers without frightening you with them.
And if the numbers are not what you hoped - if fertility treatment is part of the conversation, if high-risk care is on the table - know that those are not failures. They are tools. I use them for my patients every week. The goal is the same whether you are 28 or 42: a healthy mother and a healthy baby, and the best possible care to get there.
You do not need permission to want this. You need information, a good doctor, and the willingness to be both brave and careful at the same time. Those two things are not opposites. I learned that the hard way.
Ready to talk about your pregnancy plans? Consult Dr. Pallavi Kulkarni at Aarogya Women’s Clinic in Thakur Village, Kandivali East. Call us at +91 91366 33062, WhatsApp us, or just walk in.
Women from Kandivali East including Thakur Village, Kandivali West, Malad East, Malad West, Borivali East, Borivali West, Goregaon East and Goregaon West frequently visit for pregnancy care and gynecological consultations.
Do you have any questions?
Request An AppointmentQuestions I get asked
Is it safe to have a baby at 40?
For most women, yes. Risks such as gestational diabetes, high blood pressure, and chromosomal conditions rise modestly with age, and good prenatal care manages most of them. What changes in pregnancy at 40 is probability, not destiny.
What tests are offered in pregnancy at 40?
You will usually be offered first-trimester combined screening at 11 to 14 weeks, NIPT from around 10 weeks, a detailed anomaly scan at 18 to 22 weeks, a glucose tolerance test at 24 to 28 weeks, and growth scans later in pregnancy. All of them are optional.
Is 40 too old to have a second child?
No. Many women have a second child at 40 or later. It is not too old. It is a pregnancy that benefits from earlier booking and closer monitoring, which a good obstetrician will offer anyway.
What is the chance of Down syndrome at 40?
The chance of Down syndrome at age 40 is roughly 1 in 100 at the start of pregnancy. That means around 99 out of every 100 babies conceived at 40 do not have Down syndrome. Screening gives you much more specific information for your own pregnancy.
Should I do NIPT if I’m pregnant at 40?
NIPT is offered to most women at 40, and most accept it. It is very reliable for Down syndrome, with sensitivity above 99% in most series. Whether you accept it is your decision. Talk to your doctor about what the result would change for you.
Do I need amniocentesis if my NIPT is reassuring?
Usually not. NIPT is very reliable for Down syndrome, and most women with a reassuring result do not go on to amniocentesis. Some choose to, either for a definitive answer or because of a specific concern. Amniocentesis carries a small additional miscarriage risk, around 0.1 to 0.2% above background in experienced hands. It is a real choice, not a default.
Does pregnancy after 35 increase the risk of autism?
The evidence is mixed and modest. Some studies show a small association between advanced maternal age and autism. The paternal-age association is more consistent in the research. No prenatal test screens for autism. Vaccines do not cause autism.
Until how many weeks is termination legal in India?
Under the MTP (Amendment) Act 2021, termination is permitted up to 20 weeks on a single doctor’s opinion, up to 24 weeks on two doctors’ opinion for specific categories including substantial fetal abnormality, and beyond 24 weeks only through a Medical Board for significant fetal abnormalities.
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