Diabetic-Associated Stillbirth: Incidence, Pathophysiology, and Prevention
Section snippets
Definitions
For the purposes of this review, pregestational diabetes may include type 1 or type 2 diabetes. Gestational diabetes is that recognized only during pregnancy after specific testing. Although some cases of type 2 diabetes may be detected during pregnancy, the specific diagnosis may not be clear. These instances will be considered as gestational diabetes because of the lack of clarity of diagnosis before the pregnancy.
Stillbirth is generally defined as fetal death after 20 weeks of gestation. One
Historical perspective
Prior to the discovery of insulin, successful pregnancy was rare in women who had pregestational diabetes. In women who achieved pregnancy, the perinatal mortality rate approximated 65% [2]. Notably, however, maternal mortality was exceedingly high, approaching 30%; thus, concerns regarding the perinatal mortality rate were superceded by maternal concerns. With the discovery and then the clinical use of insulin, maternal mortality rates declined dramatically, and attention could be turned to
Epidemiology of stillbirth
Fetal deaths have declined over the past 50 years. In the 1950s, fetal death rates were reported as high as 20/1000 births. However, according to the most recent National Center for Health Statistic report from 2003 [1], fetal deaths occurred in 6.23/1000 births. However, this figure has been declined slowly over the past 20 years, while the number of infant deaths has declined by over 30% in that same time period [4]. Most of the decline in fetal deaths has occurred in gestational ages of
Causes of stillbirth
When considering stillbirth in women who have diabetes, one must remember that there are multiple causes of stillbirth for all women, and that hyperglycemia is but one cause. In a recent review from the Stillbirth Collaborative Research Network, Silver and colleagues [26] note that the causes of stillbirth are varied and in many cases unexplained. In current practice, a cause may be ascertained in only 50% of cases of stillbirth, whereas a more detailed evaluation may uncover a cause in up to
Pathophysiology of stillbirth in women who have diabetes
General consensus holds that hyperglycemia and poor glucose control contributes significantly to the events that lead to fetal death in women who have diabetes [27]. However, other causes of stillbirth cannot be discounted, and studies of fetal death in diabetic women that include a detailed analysis of the causes of fetal death find that uncontrolled hyperglycemia probably accounts for approximately half of all fetal deaths. Congenital anomalies, infection, and other known causes of stillbirth
Prevention of stillbirth in diabetic pregnancies
Key to the prevention of fetal death in women who have pregestational diabetes is comprehensive multidisciplinary care with aggressive blood sugar control. The care team, led by an experienced perinatologist, should include internists, ophthalmologists, high-risk obstetric nurses, nutritionists, social workers, and a contemporary laboratory for specialized testing when indicated [27]. A new concept for complex patient care, patient navigation, holds promise for more effective and efficient care
Summary
Diabetes, and in particularly pregestational diabetes with attendant vascular complications, is clearly a significant risk factor for stillbirth. However, a comprehensive prenatal care program, including perinatologists, dieticians, prenatal nurses, labor and delivery nurses and personnel, and social workers, can significantly improve pregnancy outcomes and decrease the risk for stillbirth in this vulnerable population that is approaching stillbirth rates that characterize normal pregnancies.
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Maternal Diabetes
2023, Avery's Diseases of the NewbornRoutine use of antenatal nonstress tests in pregnant women with diabetes–What is the practice?
2020, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :The risk of stillbirth is 4-5-fold increased in pregnancies in women with type 1 diabetes [3,4]. Several risk factors for stillbirth in these women have been described, including poor glycemic control and vascular diseases [1,2,5], but the specific underlying mechanisms are not fully known and prevention of stillbirth remains a challenge. Consequently, antepartum fetal surveillance programs in the last trimester have been implemented as routine practice in the standard care for pregnant women with preexisting diabetes [6–8].
Adenosine kinase and cardiovascular fetal programming in gestational diabetes mellitus
2020, Biochimica et Biophysica Acta - Molecular Basis of DiseaseCitation Excerpt :There are several reports on the prevalence and risk of fetal complications in a GDM pregnancy [1,2]. In general, fetuses to GDM mothers show macrosomia (prevalence ~ 7%, Odds ratio (OR) ~2) [43–45], shoulder dystocia during vaginal birth (prevalence ~ 1%, OR ~ 1.7) [46,47], congenital anomalies (prevalence ~ 1%, OR ~ 1.4) [48,49], intrauterine death at term (prevalence ~ 5%, OR ~ 2.9 for <90th weight percentile) [50], and stillbirth (prevalence varies from low, i.e. ~2%, to higher values, i.e. ~20% or more, depending on the study, OR ~ 2–5) [45,51–53], and caesarean section (prevalence ~ 9%, OR ~ 3) [45,54,55]. Also, the fetus from GDM pregnancies have higher risk of complications at or shortly after delivery, such as respiratory distress syndrome (prevalence ~ 8%, OR ~ 3.6) [56,57], neonatal hypoglycaemia first few hours after birth (prevalence ~ 25% mixing mild (≤47 mg glucose/dL) and severe (≤36 mg glucose/dL) hypoglycaemia; incidence ~34% for mild- and ~21% for severe hypoglycaemia; OR ~ 2.5) [45,58,59], hyperbilirubinemia (prevalence ~ 10–60%, OR ~ 1.8) [44,60], or hypocalcaemia (prevalence ~ 6%, OR ~ 3) [45,61–64].
Maternal Diabetes
2018, Avery's Diseases of the Newborn: Tenth EditionMaternal Diabetes
2017, Avery's Diseases of the Newborn, Tenth EditionMultidisciplinary Workup for Stillbirth at a Tertiary-Care Hospital in Northeast Mexico: Findings, Challenges and Perspectives
2024, Maternal and Child Health Journal
Supported in part by a grant from the National Institutes of Health: 5 U10 HD 049533-04.
A version of this article appeared in Obstetrics and Gynecology Clinics: Diabetes in Pregnancy (Volume 34, Issue 2, June 2007).