Elsevier

Clinics in Perinatology

Volume 34, Issue 4, December 2007, Pages 611-626
Clinics in Perinatology

Diabetic-Associated Stillbirth: Incidence, Pathophysiology, and Prevention

https://doi.org/10.1016/j.clp.2007.09.003Get rights and content

All forms of diabetes during pregnancy are associated with an increased risk for stillbirth, defined as fetal death at greater than 20 weeks. The incidence of stillbirth in women who have diabetes has decreased dramatically with improved diabetes care. Diabetic-associated stillbirth is associated with hyperglycemia, resulting in fetal anaerobic metabolism with hypoxia and acidosis. Prevention of stillbirth in women who have diabetes hinges on intensive multidisciplinary prenatal care with control of blood sugars and appropriate fetal surveillance.

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maternal mortality was exceedingly high, approaching 30%; thus, concerns regarding the perinatal mortality rate were superceded by maternal concerns.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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    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).

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