Pregnancy in peri- and postmenopausal women is associated with an increased risk of complications and represents several challenges in terms of clinical management. Women in these age groups typically fall into one of two distinct groups, those who have conceived following assisted reproductive techniques, using ovum donation and those who have conceived spontaneously. While both have age in common, they differ in terms of additional risk factors. Recipients of assisted reproductive technologies have pregnancy risks associated with that treatment, but are at lower risks of a fetus affected by aneuploidy. Furthermore, they have been rigorously screened for medical complications, but are more likely to be primiparous and have multiple pregnancies. In contrast, women conceiving spontaneously are more likely to be of high parity and have additional medical complications such as obesity, hypertension or diabetes. In addition to the increased risk of antenatal complications such as miscarriage, ectopic pregnancies, gestational diabetes and hypertension, these women have a high risk of unexplained stillbirth. They also have a very high rate of Caesarean section. All these risk factors interact to modify clinical management. However, there are no randomized trials available to guide clinical management, thus decisions must be made on a case-by-case basis.