Skip to main content

09-07-2018 | Pregnancy | Review | Article

Optimal Obstetric Management for Women with Diabetes: the Benefits and Costs of Fetal Surveillance

Journal: Current Diabetes Reports

Authors: Ukachi N. Emeruwa, Chloe Zera

Publisher: Springer US



Purpose of Review

To elaborate on the risks and benefits associated with antenatal fetal surveillance for stillbirth prevention in women with diabetes.

Recent Findings

Women with pregestational diabetes have a 3- to 5-fold increased odds of stillbirth compared to women without diabetes. The stillbirth risk in women with gestational diabetes (GDM) is more controversial; while recent data suggest the odds for stillbirth are approximately 50% higher in women with GDM at term (37 weeks and beyond) than in those without GDM, it is unclear if this risk is seen in women with optimal glycemic control. Current professional society guidelines are broad with respect to fetal testing strategies and delivery timing in women with diabetes.


The data supporting strategies to reduce the risk of stillbirth in women with diabetes are limited. Antepartum fetal surveillance should be performed to reduce stillbirth rates; however, the optimal test, frequency of testing, and delivery timing are not yet clear. Future studies of obstetric management for women with diabetes should consider not just individual but also system level costs and benefits associated with antenatal surveillance.
Peng TY, Ehrlich SF, Crites Y, Kitzmiller JL, Kuzniewicz MW, Hedderson MM, et al. Trends and racial and ethnic disparities in the prevalence of pregestational type 1 and type 2 diabetes in Northern California: 1996–2014. Am J Obstet Gynecol. 2017;216(2):177–e1. CrossRefPubMed
Feig DS, Hwee J, Shah BR, Booth GL, Bierman AS, Lipscombe LL. Trends in incidence of diabetes in pregnancy and serious perinatal outcomes: a large, population-based study in Ontario, Canada, 1996–2010. Diabetes Care. 2014;37(6):1590–6. CrossRefPubMed
Correa A, Bardenheier B, Elixhauser A, Geiss LS, Gregg E. Trends in prevalence of diabetes among delivery hospitalizations, United States, 1993–2009. Matern Child Health J. 2015;19(3):635–42. CrossRefPubMedPubMedCentral
Thorpe LE, Berger D, Ellis JA, Bettegowda VR, Brown G, Matte T, et al. Trends and racial/ethnic disparities in gestational diabetes among pregnant women in New York City, 1990–2001. Am J Public Health. 2005;95(9):1536–9. CrossRefPubMedPubMedCentral
Dabelea D, Snell-Bergeon JK, Hartsfield CL, Bischoff KJ, Hamman RF, McDuffie RS. Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM screening program. Diabetes Care. 2005;28(3):579–84. CrossRefPubMed
Ferrara A, Kahn HS, Quesenberry CP, Riley C, Hedderson MM. An increase in the incidence of gestational diabetes mellitus: northern California, 1991–2000. Obstet Gynecol. 2004;103(3):526–33. CrossRefPubMed
Getahun D, Nath C, Ananth CV, Chavez MR, Smulian JC. Gestational diabetes in the United States: temporal trends 1989 through 2004. Am J Obstet Gynecol. 2008;198(5):525–e1. CrossRefPubMed
Rosenstein MG, Cheng YW, Snowden JM, Nicholson JM, Doss AE, Caughey AB. The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. Am J Obstet Gynecol. 2012;206(4):309–e1. CrossRefPubMedPubMedCentral
Magon N, Chauhan M. Pregnancy in type 1 diabetes mellitus: how special are special issues? N Am J Med Sci. 2012 Jun;4(6):250–6. CrossRefPubMedPubMedCentral
Negrato CA, Mattar R, Gomes MB. Adverse pregnancy outcomes in women with diabetes. Diabetol Metab Syndr. 2012;4(1):41. CrossRefPubMedPubMedCentral
Lauenborg J, Mathiesen E, Ovesen P, Westergaard JG, Ekbom P, Mølsted-Pedersen L, et al. Audit on stillbirths in women with pregestational type 1 diabetes. Diabetes Care. 2003;26(5):1385–9. CrossRefPubMed
Mathiesen ER, Ringholm L, Damm P. Stillbirth in diabetic pregnancies. Best practice & research Clinical obstetrics & gynaecology. 2011;25(1):105–11. CrossRef
Reddy UM, Laughon SK, Sun L, Troendle J, Willinger M, Zhang J. Prepregnancy risk factors for antepartum stillbirth in the United States. Obstet Gynecol. 2010;116(5):1119–26. CrossRefPubMedPubMedCentral
Stillbirth Collaborative Research Network Writing Group. Association between stillbirth and risk factors known at pregnancy confirmation. JAMA. 2011;306(22):2469–79. CrossRef
Casson IF, Clarke CA, Howard CV, McKendrick O, Pennycook S, Pharoah PO, et al. Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study. BMJ. 1997;315(7103):275–8. CrossRefPubMedPubMedCentral
Danish National Board of Health Sundhedsstatistikken: The Medical Birth Register: summary of birth statistics 1994 and 1995. No. 6. Copenhagen, Denmark, Munksgaard, 1997.
Macintosh MC, Fleming KM, Bailey JA, Doyle P, Modder J, Acolet D, et al. Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study. BMJ. 2006;333(7560):177. CrossRefPubMedPubMedCentral
Bell R, Bailey K, Cresswell T, Hawthorne G, Critchley J, Lewis-Barned N. Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes. BJOG Int J Obstet Gynaecol. 2008;115(4):445–52. CrossRef
Dudley DJ. Diabetic-associated stillbirth: incidence, pathophysiology, and prevention. Clin Perinatol. 2007;34(4):611–26. CrossRefPubMed
Jovanovic L, Peterson CM. Management of the pregnant, insulin-dependent diabetic woman. Diabetes Care. 1980;3(1):63–8. CrossRefPubMed
Schmidt MI, Duncan BB, Reichelt AJ, Branchtein L, Matos MC, e Forti AC, et al. Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care. 2001;24(7):1151–5. CrossRefPubMed
Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352(24):2477–86. CrossRefPubMed
Cundy T, Gamble G, Neale L, Elder R, McPherson P, Henley P, Rowan J. Differing causes of pregnancy loss in type 1 and type 2 diabetes. Diabetes Care 2007 22.
Berger H, Melamed N. Timing of delivery in women with diabetes in pregnancy. Obstetric Medicine. 2014;7(1):8–16. CrossRefPubMedPubMedCentral
Brecher A, Tharakan T, Williams A, Baxi L. Perinatal mortality in diabetic patients undergoing antepartum fetal evaluation: a case–control study. J Matern Fetal Neonatal Med. 2002;12(6):423–7. PubMed
Jensen DM, Damm P, Moelsted-Pedersen L, Ovesen P, Westergaard JG, Moeller M, et al. Outcomes in type 1 diabetic pregnancies: a nationwide, population-based study. Diabetes Care. 2004;27(12):2819–23. CrossRefPubMed
Silva I, Higgins C, Swerdlow AJ, Laing SP, Slater SD, Pearson DW, et al. Birthweight and other pregnancy outcomes in a cohort of women with pre-gestational insulin-treated diabetes mellitus, Scotland, 1979–95. Diabet Med. 2005;22(4):440–7. CrossRef
Penney GC, Mair G, Pearson DW. Outcomes of pregnancies in women with type 1 diabetes in Scotland: a national population-based study. BJOG Int J Obstet Gynaecol. 2003;110(3):315–8. CrossRef
Mondestin MA, Ananth CV, Smulian JC, Vintzileos AM. Birth weight and fetal death in the United States: the effect of maternal diabetes during pregnancy. Am J Obstet Gynecol. 2002;187(4):922–6. CrossRefPubMed
Cundy T, Gamble G, Townend K, Henley PG, MacPherson P, Roberts AB. Perinatal mortality in type 2 diabetes mellitus. Diabet Med. 2000;17(1):33–9. CrossRefPubMed
Clausen TD, Mathiesen E, Ekbom P, Hellmuth E, Mandrup-Poulsen T, Damm P. Poor pregnancy outcome in women with type 2 diabetes. Diabetes Care. 2005;28(2):323–8. CrossRefPubMed
Dunne F, Brydon P, Smith K, Gee H. Pregnancy in women with type 2 diabetes: 12 years outcome data 1990–2002. Diabet Med. 2003;20(9):734–8. CrossRefPubMed
Brydon, et al. Pregnancy outcome in women with type 2 diabetes mellitus needs to be addressed. Int J Clin Pract. 2000;54:418–9. PubMed
Patel KR, White FV, Deutsch GH. Hepatic steatosis is prevalent in stillborns delivered to women with diabetes mellitus. J Pediatr Gastroenterol Nutr. 2015;60(2):152–8. CrossRefPubMed
Caughey AB, Sundaram V, Kaimal AJ, Cheng YW, Gienger A, Little SE, Lee JF, Wong L, Shaffer BL, Tran SH, Padula A. Maternal and neonatal outcomes of elective induction of labor. Evidence report/technology assessment 2009;(176):1.
Kjos SL, Leung A, Henry OA, Victor MR, Paul RH, Medearis AL. Antepartum surveillance in diabetic pregnancies: predictors of fetal distress in labor. Am J Obstet Gynecol. 1995;173(5):1532–9. CrossRefPubMed
Darney BG, Snowden JM, Cheng YW, Jacob L, Nicholson JM, Kaimal A, et al. Elective induction of labor at term compared with expectant management: maternal and neonatal outcomes. Obstet Gynecol. 2013;122(4):761–9. CrossRef
Signore C, Freeman RK, Spong CY. Antenatal testing–a reevaluation: executive summary of a Eunice Kennedy Shriver National Institute of Child Health and Human Development workshop. Obstet Gynecol. 2009;113(3):687–701. CrossRefPubMedPubMedCentral
Ray M, Freeman R, Pine S, Hesselgesser R. Clinical experience with the oxytocin challenge test. Am J Obstet Gynecol. 1972;114(1):1–9. CrossRefPubMed
Nageotte MP. Antenatal testing: diabetes mellitus. Seminars in Perinatol. 2008;32(4):269–70. WB Saunders CrossRef
Freeman RK, Anderson G, Dorchester W. A prospective multi-institutional study of antepartum fetal heart rate monitoring: I. Risk of perinatal mortality and morbidity according to antepartum fetal heart rate test results. Am J Obstet Gynecol. 1982;143(7):771–7. CrossRefPubMed
Freeman RK, Anderson G, Dorchester W. A prospective multi-institutional study of antepartum fetal heart rate monitoring II Contraction stress test versus nonstress test for primary surveillance. Am J Obstet Gynecol. 1982;143:778. CrossRefPubMed
Lagrew DC Jr. The contraction stress test. Clin Obstet Gynecol. 1995;38:11–25. CrossRefPubMed
Warland J, O’Brien LM, Heazell AE, Mitchell EA. An international internet survey of the experiences of 1,714 mothers with a late stillbirth: the STARS cohort study. BMC Pregnancy and Childbirth. 2015;15(1):172. CrossRefPubMedPubMedCentral
Mangesi L, Hofmeyr GJ, Smith V, Smyth RM. Fetal movement counting for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews. 2015;(10).
Metzger BE, Buchanan TA, Coustan DR, De Leiva A, Dunger DB, Hadden DR, et al. Summary and recommendations of the fifth international workshop-conference on gestational diabetes mellitus. Diabetes Care. 2007;30(Supplement 2):S251–60. CrossRef
Heazell AE, Weir CJ, Stock SJ, Calderwood CJ, Burley SC, Froen JF, et al. Can promoting awareness of fetal movements and focusing interventions reduce fetal mortality? A stepped-wedge cluster randomised trial (AFFIRM). BMJ Open. 2017;7(8):e014813. CrossRefPubMedPubMedCentral
Kim C. Gestational diabetes: risks, management, and treatment options. Int J Women's Health. 2010;2:339. CrossRef
World Health Organization. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: World Health Organization; 2000.
MacDorman MF, Gregory EC. Fetal and perinatal mortality: United States, 2013. National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2015;64(8):1–24.
Bracero L, Schulman H, Fleischer A, Farmakides G, Rochelson B. Umbilical artery velocimetry in diabetes and pregnancy. Obstet Gynecol. 1986;68(5):654–8. PubMed
Bracero LA, Figueroa R, Byrne DW, Han HJ. Comparison of umbilical Doppler velocimetry, nonstress testing, and biophysical profile in pregnancies complicated by diabetes. J Ultrasound Med. 1996;15(4):301–8. CrossRefPubMed
Bracero LA, Haberman S, Byrne DW. Maternal glycemic control and umbilical artery Doppler velocimetry. J Matern Fetal Neonatal Med. 2002;12(5):342–8. CrossRefPubMed
Wong SF, Chan FY, Cincotta RB, McIntyre DH, Stone M. Use of umbilical artery Doppler velocimetry in the monitoring of pregnancy in women with pre-existing diabetes. Aust N Z J Obstet Gynaecol. 2003;43(4):302–6. CrossRefPubMed
Landon MB, Gabbe SG, Bruner JP, Ludmir J. Doppler umbilical artery velocimetry in pregnancy complicated by insulin-dependent diabetes mellitus. Obstet Gynecol. 1989;73(6):961–5. PubMed
Grivell RM, Alfirevic Z, Gyte GM, Devane D. Antenatal cardiotocography for fetal assessment. The Cochrane Library. 2015
Lalor JG, Fawole B, Alfirevic Z, Devane D. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database of Systematic Reviews. 2008;(1).
Alfirevic Z, Stampalija T, Dowswell T. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. The Cochrane Library. 2017.
Gestational diabetes mellitus. Practice Bulletin No. 180. Am Coll Obstet Gynecol. 2017;130:e17–31. CrossRef
• Society for Maternal Fetal Medicine. Five More Things Physicians and Patients Should Question. Choosing Wisely, ABIM Foundation. 2016. This provides a comprehensive summary of obstetric management of PGDM.
Pregestational diabetes mellitus. ACOG Practice Bulletin No. 60. ACOG Practice Bulletin #60: Pregestational Diabetes Mellitus. American College of Obstetricians and Gynecologists: Obstet Gynecol. 2005;105:675–85.
Landon MB, Langer O, Gabbe SG, Schick C, Brustman L. Fetal surveillance in pregnancies complicated by insulin-dependent diabetes mellitus. Am J Obstet Gynecol. 1992;167(3):617–21. CrossRefPubMed
Landon MB, Vickers S. Fetal surveillance in pregnancy complicated by diabetes mellitus: is it necessary? J Matern Fetal Neonatal Med. 2002;12(6):413–6. CrossRefPubMed
• Society for Maternal Fetal Medicine. Checklist for Antepartum Care of Pre-gestational (Type 1 or Type 2) Diabetes. SMFM. 2016. This provides a comprehensive summary of obstetric management of PGDM .
Persson M, Norman M, Hanson U. Obstetric and perinatal outcomes in type 1 diabetic pregnancies: a large, population-based study. Diabetes Care. 2009;32(11):2005–9. CrossRefPubMedPubMedCentral
Sibai BM, Caritis SN, Hauth JC, MacPherson C, VanDorsten JP, Klebanoff M, et al. Preterm delivery in women with pregestational diabetes mellitus or chronic hypertension relative to women with uncomplicated pregnancies. Am J Obstet Gynecol. 2000;183(6):1520–4. CrossRefPubMed
•• Caughey AB, Valent AM. When to Deliver Women with Diabetes in Pregnancy? Am J Perinatol. 2016;33(13):1250–4. Reviews the existing literature on PGDM and GDM to provide a framework for determining delivery timing. CrossRefPubMed
American Diabetes Association. 13. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes—2018. Diabetes Care. 2018;41(Supplement 1):S137–43. CrossRef
Eunice Kennedy Shriver National Institute of Child Health. A Randomized Trial of Induction Versus Expectant Management (ARRIVE).
Graves CR. Antepartum fetal surveillance and timing of delivery in the pregnancy complicated by diabetes mellitus. Clin Obstet Gynecol. 2007;50(4):1007–13. CrossRefPubMed
Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360(2):111–20.
Rabie NZ, Bird TM, Magann EF, Hall RW, McKelvey SS. ADHD and developmental speech/language disorders in late preterm, early term and term infants. J Perinatol. 2015;35(8):660–4. CrossRefPubMed
Gold KJ, Sen A, Xu X. Hospital costs associated with stillbirth delivery. Matern Child Health J. 2013;17(10):1835–41. CrossRefPubMedPubMedCentral
Mistry H, Heazell AE, Vincent O, Roberts T. A structured review and exploration of the healthcare costs associated with stillbirth and a subsequent pregnancy in England and Wales. BMC Pregnancy and Childbirth. 2013;13(1):236. CrossRefPubMedPubMedCentral
Niu B, Lee VR, Cheng YW, Frias AE, Nicholson JM, Caughey AB. What is the optimal gestational age for women with gestational diabetes type A1 to deliver? Am J Obstet Gynecol. 2014;211(4):418–e1. CrossRefPubMedPubMedCentral
Trudell AS, Tuuli MG, Colditz GA, Macones GA, Odibo AO. A stillbirth calculator: development and internal validation of a clinical prediction model to quantify stillbirth risk. PLoS One. 2017;12(3):e0173461. CrossRefPubMedPubMedCentral

New additions to the Adis Journal Club

A selection of topical peer-reviewed articles from the Adis journals, curated by the editors.

ADA 2022 coverage

Access the latest news and expert insight from the ADA 82nd Scientific Sessions