At least one year is the ideal pregnancy spacing time for the health of mother and baby

  

One to one and a half year is the ideal spacing time between pregnancies according to researchers from the University of British Columbia (B.C.) and the Harvard T.H. Chan School of Public Health.

The study found an increased risk of premature births, maternal morbidity and mortality, and adverse neonatal outcome following an interpregnancy interval of fewer than 12 months in women of all ages. However, women who were 35 or more were at increased risks of maternal mortality or severe morbidity, while women aged 20 to 34 years were at increased risk of preterm labor and adverse fetal and infant outcomes.

In this large cohort study published online October 29 in JAMA Internal Medicine, the researchers looked at data from 148,544 pregnancies in B.C. to examine the relationship between interpregnancy interval and adverse pregnancy. The data was gathered from billing codes, hospitalization data, birth records, prescription data for infertility information, and census records for a period of 10 years (2004 to 2014).

The study is the most extensive and in-depth evaluation of the relationship between pregnancy spacing and maternal age. Currently, it is unknown whether older women face the same risk as younger women because of a shorter interpregnancy interval.

Women aged 35 and more who conceived within six months of a previous birth, faced 1.2 percent risk (12 cases per 1,000 pregnancies) of maternal mortality or severe morbidity (mechanical ventilation, blood transfusion >3 U, intensive care unit admission, and organ failure). Keeping an interpregnancy interval of 18 months, however, reduced the risk to 0.5 percent (five cases per 1,000 pregnancies).

For younger women, who conceived within six months of last childbirth, the researchers found an 8.5 percent risk (85 cases per 1,000 pregnancies) of spontaneous preterm birth, but the risk dropped to 3.7 percent (37 cases per 1,000 pregnancies) if the women waited 18 months before the next conception. 

Among older women, the risk of spontaneous preterm labor was about six percent (60 cases per 1,000 pregnancies) at the six-month interval, compared to 3.4 percent (34 cases per 1,000 pregnancies) at the 18-month interval.

“Our study found increased risks to both mother and infant when pregnancies are closely spaced, including for women older than 35,” said the study’s lead author Laura Schummers in a University of British Columbia news release. Dr. Schummers is a postdoctoral fellow in the UBC department of family practice who carried out the study as part of her dissertation at the Harvard T.H. Chan School of Public Health. “The findings for older women are particularly important, as older women tend to more closely space their pregnancies and often do so intentionally,” she further added. 

Senior author Dr. Wendy Norman, associate professor in the UBC department of family practice, said these findings of a shorter optimal interval are encouraging for women over 35 who are planning their families.

“Older mothers for the first time have excellent evidence to guide the spacing of their children,” said Norman. “Achieving that optimal one-year interval should be doable for many women and is clearly worthwhile to reduce complication risks.”

JAMA Internal Medicine Full Text

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Just wait a minute, and you save thousands of preterm babies a year

babycenter.com

   

November 17 is celebrated as World Prematurity Day and theme for this year is ‘let them thrive.’

According to WHO An estimated 15 million babies are born preterm every year – more than 1 in 10 babies around the world and this number is rising. Preterm birth complications are the leading cause of death for children under 5.

Well, the obstetricians and health care personal assisting in child birth could save thousands of lives by waiting 60 seconds before clamping the umbilical cord after birth instead of clamping it immediately reports the results of a systematic review and meta-analysis led by the University of Sydney's National Health and Medical Research Council Clinical Trials Centre.

The review will be published in forthcoming issue of American Journal of Obstetrics and Gynecology.

The researchers  looked into data from 18 randomized controlled trials that compared delayed vs early clamping amounting to total of 2834 infants born before 37 weeks' gestation. The cord was clamped after 60 seconds in infants allocated to delayed cord clamping group.

Infants who had their cord clamped after 1 minute faced a 32% reduced risk of mortality and 33 infants need to have delayed cord clamping to save one infant (number need to treat = 33).

Out of 18 trials, 3 trials consisted of about 1000 infants born before ≤28 weeks’ gestation. They had a 30% reduction in mortality and the number need to treat was 20.

The two groups were comparable for Apgar scores, intubation for resuscitation, admission temperature, mechanical ventilation, intraventricular hemorrhage, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late-onset sepsis, or retinopathy of prematurity.

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Delay in cord clamping improved the hematocrit by 3% and 10% fewer babies required blood transfusion.

The side effects of delayed clamping were polycythemia and hyperbilirubinemia.

"The review shows for the first time that simply clamping the cord 60 seconds after birth improves survival," said the University of Sydney's Professor William Tarnow-Mordi, senior author.

"It confirms international guidelines recommending delayed clamping in all preterm babies who do not need immediate resuscitation."

"We estimate that for every thousand very preterm babies born more than ten weeks early, delayed clamping will save up to 100 additional lives compared with immediate clamping," said the University of Sydney's Associate Professor David Osborn, the review's lead author and a neonatal specialist at Royal Prince Alfred Hospital.

"This means that, worldwide, using delayed clamping instead of immediate clamping can be expected to save between 11,000 and 100,000 additional lives every year."

The study findings are in accordance with a second Australian study published in The New England Journal of Medicine. The Australian study enrolled about 1500 babies, from25 centers in 7 countries. The babies were born on an average 10 weeks early. Delayed cord clamping saved 3% more babies, as compared to immediate cord clamping (mortality was  6% vs 9%)(p=0.03).

Currently, WHO recommends waiting at least 60 seconds before cord clamping in premature and term babies.

ACOG also recommends, “a delay in umbilical cord clamping for all healthy infants for at least 30-60 seconds after birth given the numerous benefits to most newborns.” 

Full Text

ACOGrecommendations for delayed cord clamping

WHO recommendations for delayed cord clamping

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17α-hydroxyprogesterone caproate plus cerclage have cumulative effect in preventing recurrent preterm birth and improving perinatal outcome.

Clinical Pearls:    

·         Women receiving transvaginal cerclage plus 17α-hydroxyprogesterone caproate had a 69% relative reduction in delivery at less than 24 weeks of gestation when compared with women receiving cerclage alone. 

·         These women also delivered babies that were heavier (2,547±1,009 g) as compared to women with only cerclage (2,326±1,250 g). (P=.03)

·         They also had fewer neonates with with 5-minute Apgar score less than 7,10% in the cerclage plus 17α-hydroxyprogesterone caproate cohort compared with 20% in the control cohort (P=.04).

·         There was no significant difference in delivery at less than 28 and less than 37 weeks of gestation, neonatal complications and admission to NICU between the two cohorts. 

·         The pilot study results indicate that the two therapies, 17α-hydroxyprogesterone caproate and cerclage, appear to be cumulative in their benefit.

Preterm birth is a major cause of neonatal morbidity and mortality with most preterm-related deaths occurring among babies who were born very preterm (before 32 weeks). Preterm birth is also a leading cause of long-term neurological disabilities in children.[1]

As per WHO statistics every year nearly 15 million babies are born preterm (1 in 10 babies) and it was responsible for nearly 1 million deaths in 2013.

In India, 3,341,000 babies are born preterm each year and 361,600 children under five die due to direct preterm complications.[2] More than 90% of babies born before 28 weeks of gestation in developing countries succumb within first few days of birth while in developed countries less than 10% babies of the same gestation die.[3]

Beside other risk factors, a history of prior preterm birth is the single most important risk factor for subsequent preterm birth.

A meta-analysis by Berghella V et al published in obstetrics and gynecology journal compared the outcome in singleton gestations with prior preterm birth that were managed either by cervical length screening with cerclage for short cervical length or history-indicated cerclage. The study concluded that cerclage is not indicated in every woman with previous history of preterm birth but reserved for the minority of women who develop a short cervical length.[4]

ACOG February 2014 Practice Bulletin reviews the guidelines for cervical cerclage in women with a history of preterm birth based on history, physical examination, and ultrasonographic findings.[5]

The second modality of treatment for women with a prior preterm birth is 17α-hydroxyprogesterone caproate. A study by Meis  PJ et al showed that weekly  injection of 250 mg 17 alpha-hydroxyprogesterone caproate reduced the risk of preterm birth before 37 weeks by nearly 34%.[6]

The additive effects of cerclage plus 17 alpha-hydroxyprogesterone caproate versus only cerclage in patients with a prior spontaneous preterm delivery has not been studied.  

The recent study published in obstetrics and gynecology November 2016 issue compared the prolongation of pregnancy and perinatal outcome in   among women with a prior preterm birth who received cerclage compared with cerclage plus 17α-hydroxyprogesterone caproate.

This retrospective cohort study recruited patients with vaginal cerclage and prior history of preterm birth between 16-36 weeks of gestation were identified over a course of 10-year period from July 2002 to May 2012.

A total of 411 women with cerclage were identified out of whom 260 met the inclusion criteria.  Of these, the control arm of 171 women continued the pregnancy with cerclage alone while 89 women in the study arm received 250 mg of 17α-hydroxyprogesterone caproate injections weekly along with the cerclage. In 46 women with a history based cerclage the injections were started prior to surgery and in 43 patients they were started after the procedure.

The primary outcome was delivery before 24 weeks while the secondary outcomes were delivery at less than 28 and less than 37 weeks of gestation as well as preterm prelabor rupture of membranes (PROM), delivery mode, neonatal intensive care unit admission, 5-minute Apgar score less than 7, necrotizing enterocolitis, grade 3 or 4 intraventricular hemorrhage, and birth weight.

The two groups were identical in terms of maternal demographics and gestational age of receiving cerclage.

It was seen that women receiving transvaginal cerclage plus 17α-hydroxyprogesterone caproate had a 69% relative reduction in delivery at less than 24 weeks of gestation when compared with women receiving cerclage alone. 

These women also delivered babies that were heavier (2,547±1,009 g) as compared to women with only cerclage (2,326±1,250 g). (P=.03)

They also had fewer neonates with with 5-minute Apgar score less than 7. 10% in the cerclage plus 17α-hydroxyprogesterone caproate cohort compared with 20% in the control cohort (P=.04).

There was no significant difference in delivery at less than 28 and less than 37 weeks of gestation between the two cohorts. 

 Both the cohorts also have similar mode of delivery, neonatal intensive care unit admission, intraventricular hemorrhage (grade 3 or 4), or necrotizing enterocolitis.

A secondary analysis studies the relationship between examination and ultrasound indicated cerclage with the additive effect of 17α-hydroxyprogesterone caproate as compared to history indicated cerclage. There was a 91% and 89% reduction in delivery at less than 24 and less than 28 weeks of gestation, respectively when progesterone was continued.

The study has multiple strengths and limitations. The investigators understand that the study had a small sample size and limitations of adjusting for several variables. They also caution the readers to interpret the results of the study carefully as more large, adequately powered multicenter prospective trial studies are needed before a recommendation can be made.

The pilot study results indicate that the two therapies, 17α-hydroxyprogesterone caproate and cerclage, appear to be cumulative in their benefit.

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[1]http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm

[2] http://www.everypreemie.org/wp-content/uploads/2016/02/India-revJan2016.pdf

[3] http://www.who.int/mediacentre/factsheets/fs363/en/

[4] http://journals.lww.com/greenjournal/Abstract/2011/07000/Cervical_Length_Screening_With.20.aspx

[5] Cerclage for the management of cervical insufficiency. Practice Bulletin No. 142. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:372–9.

[6] https://www.ncbi.nlm.nih.gov/pubmed/12802023