Updates regarding effect of SIPS on mother and fetus and role of contraception

1. Short interpregnancy spacing
and its impact
Dr. Dhan Bahadur Shrestha
Intern, Shree Birendra Hospital
medhan75@gmail.com5/31/2017

2. Case history
• 29 years/ female P2+0, L1 at 38+6 WOG not in labour with h/o
previous CS with short spacing
• Undergone LSCS ON 2074/02/08
• Delivered an alive, healthy, female baby, 2430 gm
medhan75@gmail.com5/31/2017

3. Management
• Following LSCS she kept under observation in postdelivery cabin for
24 hour.
• Then she was shifted to post natal ward and discharged after dressing
on 3rd day
medhan75@gmail.com5/31/2017

4. Short interpregnancy birth spacing
• Healthy People 2020 recommends, the interpregnancy interval (birth
to subsequent conception) should be greater than 18 months. If it is
less it is defined as SIPS.*
• Adverse birth outcomes are associated with short and very long birth
intervals, so, WHO recommends an interval of at least 24 months
from a live birth to the next pregnancy.#
*http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=13.
#Grundy E, et al. J Epidemiol Community Health 2014; 68:958–964. doi:10.1136/jech-2014-204191
medhan75@gmail.com5/31/2017

5. Factors for short interpregnancy birth spacing
• Common in developing countries
• Associated with social, cultural, and economic factors, as well as a
lack of family planning
• Unstable lifestyle, postpartum stress, inadequate use of health care
services
medhan75@gmail.com5/31/2017

6. Global perspectives
• Of 3,006 participants, 26.5% had a repeat pregnancy within 18 months:
1.9% occurred within 6 months, 8.1% between 6 and 12 months, and
16.5% between 12 and 18 months.
• Less than 2% of women with SIPIs of 18 months or fewer reported
any contraceptive use in the postpartum period and no pregnancies
occurred with the use of very effective methods, including long-acting
reversible contraception
Masinter LM, Dina B, Kjerulff K, Feinglass J. Short Interpregnancy Intervals: Results from the First Baby Study. Women's Health
Issues. 2017 Apr 11.
medhan75@gmail.com5/31/2017

7. Where are we??
• About 39% of primiparous women gave their first child birth within
1 year of marriage
• 23% of multiparous women had short preceding interbirth intervals
(<24 months).
• The average birth spacing among the multiparous group was 44.9
(SD 21.8) months.
• Median age at marriage is 17.5 years in 2011
• The median maternal age at first birth is 20.2 years.
• Subsequent births are likely, especially if the first child is not a boy
Karkee R and Lee AH (2016) Birth Spacing of Pregnant Women in Nepal: A Community-Based Study. Front. Public
Health 4:205. doi: 10.3389/fpubh.2016.00205
medhan75@gmail.com5/31/2017

8. Impact
• Closely spaced births are associated with poor outcomes for the
mother and subsequent child.
• Maternal health, particularly nutritional status, suffers when births
are closely spaced
• Uterine rupture in women attempting vaginal birth after a C-section,
uteroplacental bleeding, preeclampsia, maternal death, Post partum
endometritis etc.
• Interpregnancy intervals of 6-14 months were significantly associated
with increased risk of premature rupture of membranes.
Conde‐Agudelo A et al. Effects of birth spacing on maternal, perinatal, infant, and child health: a systematic review of causal
mechanisms. Studies in family planning. 2012 Jun 1;43(2):93-114.
Razzaque A. et al. Pregnancy spacing and maternal morbidity in Matlab, Bangladesh. Int J Gynaecol Obstet 2005;89(Suppl 1):S41-medhan75@gmail.com5/31/2017

9. Maternal health
• Among women with the same pregnancy weight gain in the first
pregnancy and the same number of inter-pregnancy intervals (12 and
18 months or ≥18 months), the hazard rate of obesity increased 2.43-
fold for every additional inter-pregnancy interval of <12 months
Davis EM, Babineau DC, Wang X, Zyzanski S, Abrams B, Bodnar LM, Horwitz RI. Short inter-pregnancy intervals, parity, excessive
pregnancy weight gain and risk of maternal obesity. Maternal and child health journal. 2014 Apr 1;18(3):554-62.
medhan75@gmail.com5/31/2017

10. Following CS
• For inter-delivery intervals up to 18 months, the uterine rupture rate
was 2.25% (seven of 311) compared with 1.05% (22 of 2098) with
intervals of 19 months or longer (P= 0 .07). *
• Rate of uterine rupture was 4.8% for patients with an inter-
delivery interval of ≤12 months of gestation, 2.7% for patients
with an interval between 13 and 24 months of gestation, 0.9%
for patients with an interval between 25 and 36 months of
gestation, and 0.9% for patients with an interval of >36 months
of gestation (P = .04).#
*Shipp TD et al. Interdelivery interval and risk of symptomatic uterine rupture. Obstetrics & Gynecology. 2001 Feb 28;97(2):175-7.
#Bujold E et al. Interdelivery interval and uterine rupture. Am jr obstetr gynecol. 2002 Nov 30;187(5):1199-202.medhan75@gmail.com5/31/2017

11. CS
• The VBAC success rate was 79.0% for patients with an interdelivery
interval less than 19 months compared with 85.5% for patients with
an interval delivery greater than or equal to 19 months (P= .12).#
#Huang WH et al. Interdelivery interval and the success of vaginal birth after cesarean delivery. Obstetrics & Gynecology. 2002
Jan 31;99(1):41-4.
medhan75@gmail.com5/31/2017

12. Neonatal risk in VBAC
• TOLAC was associated with an increased risk of neonatal depression
[OR 3.6] and neonatal intensive care unit admission (OR 1.9).
• Significant risk factors for emergency cesarean: no prior vaginal
delivery (OR 1.8), index emergency cesarean during labor (OR 3.0),
maternal age ≥35 years (OR 1.9), pre-pregnancy body mass index ≥30
(OR 2.1), and birthweight 4000–4499 g.
Studsgaard A. et al. Trial of labor compared to repeat cesarean section in women with no other risk factors than a prior cesarean
delivery. Acta obstetricia et gynecologica Scandinavica. 2013 Nov 1;92(11):1256-63.
medhan75@gmail.com5/31/2017

13. Neonate
• Women with very short IPI and high parity may have a higher risk of
having LBW infants.*
• Patients with short interval of less than 12 month had higher rates of
preterm deliveries (11.9% versus 4.9–6.6% in the other groups;
p < 0.001).# (No significant uterine rupture or Post partum death)
• Short interpregnancy intervals (<6 months) was associated positively
with preterm delivery and low birthweight but not for SGA.$
*Merklinger‐Gruchala A, Jasienska G, Kapiszewska M. American Journal of Human Biology. 2015 Sep 10;27(5):660-6.
# Kessous R, Sheiner E. The Journal of Maternal-Fetal & Neonatal Medicine. 2013 Jul 1;26(10):1003-6.
$ De Weger FJ.et al. American journal of obstetrics and gynecology. 2011 May 31;204(5):421-e1.medhan75@gmail.com5/31/2017

14. Mortality
• Children with shorter preceding intervals had increased odds of both
neonatal (<24 months, OR: 1.61) and under-five mortality (<24
months, OR: 1.48).*
• Birth interval of shorter than 18 months had statistically significant
increased odds of SGA (aOR: 1.51), preterm (aOR: 1.58) and infant
mortality (aOR: 1.83)#
*Kozuki N, Walker N. Exploring the association between short/long preceding birth intervals and child mortality: using reference
birth interval children of the same mother as comparison. BMC public health. 2013 Sep 17;13(3):S6.
# Kozuki N. et al. The associations of birth intervals with small-for-gestational-age, preterm, and neonatal and infant mortality: a
meta-analysis. BMC public health. 2013 Sep 17;13(3):S3.
medhan75@gmail.com5/31/2017

15. Abnormalities
• Second-born children conceived after an IPI of <12 months had more
than threefold increased odds of autism relative to those with IPIs of
≥36 months.#
Cheslack-Postava K, Liu K, Bearman PS. Closely spaced pregnancies are associated with increased odds of autism in California
sibling births. Pediatrics. 2011 Feb 1;127(2):246-53.
medhan75@gmail.com5/31/2017

16. Index child
• In index child of women with RRB, increased child maltreatment,
behavior problems, and developmental problems is seen.
• Verbal reasoning and short-term memory, lower overall cognitive
functioning of index children of women with an RRB
Crowne SS, Gonsalves K, Burrell L, McFarlane E, Duggan A. Relationship between birth spacing, child maltreatment, and child
behavior and development outcomes among at-risk families. Maternal and child health journal. 2012 Oct 1;16(7):1413-20.
medhan75@gmail.com5/31/2017

17. What next???
Adequate spacing of pregnancy to reduce pathology of pregnancy:
 Anaemia and its adverse consequences including blood transfusion hazards.
 Hypertensive diseases and its complications including life-threatening
eclampsia, myocardial failure, cerebrovascular accidents, HELLP and DIC.
Nutritional deficiencies.
Reduced incidence of IUGR, preterm labour, chronic foetal hypoxia.
Thereby leading to reduced caesarean deliveries along with operative adverse
eventualities.
Dixit S. Measures taken for spacing of pregnancy as performance indicators of family welfare and MCH care. J. Evolution
Med. Dent. Sci. 2016;5(99):7307-7309, DOI: 10.14260/Jemds/2016/1654
medhan75@gmail.com5/31/2017

18. Other…..
1. The first child will get full period of lactation as is due to it
2. The first child will get the undivided attention of the parents along with tender loving
care.
3. The economic burden would be half the amount, which they would have for 2 children
within 2 or 1 year.
4. Mother would get adequate time for recuperation from pregnancy, parturition and
surgery if any.
5. The physical, physiological, biochemical and psychological burden and changes of
pregnancy will require 2 to 3 years to revert back to near pre-pregnancy status.
6. Mother will be mentally ready to undertake a pregnancy usually after 2 years of previous
pregnancy.
7. At the age of 3 years the child will be more amenable for oral instructions, will understand
and implement its mother’s orders and advices. Three-year child understands about safety
and precautions, thus allowing the mother to have more free time.
8. The incidence of PROM, preterm labour, pathology of pregnancy is low in an adequately
spaced pregnancy, i.e. > 2 years.
Dixit S. Measures taken for spacing of pregnancy as performance indicators of family welfare and MCH care. J. Evolution
Med. Dent. Sci. 2016;5(99):7307-7309, DOI: 10.14260/Jemds/2016/1654
medhan75@gmail.com5/31/2017

19. Options
• Overall, the provision of
contraception and safe abortion is
important to prevent maternal
deaths and preventing or delaying
pregnancy in women not
intending to be pregnant or those
at higher risk of complications.
Ganatra B, Faundes A. Role of birth spacing, family planning services, safe abortion services and post-abortion care in reducing
maternal mortality. Best Practice & Research Clinical Obstetrics & Gynaecology. 2016 Oct 31;36:145-55.
medhan75@gmail.com5/31/2017

20. Thank
youmedhan75@gmail.com5/31/2017