The risk of stillbirth in pregnancies before and after the onset of diabetes

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2 =82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2 =82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2 =0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2 =0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2 =87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2 =0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

A protocol for a systematic review of behaviour change techniques used in the context of stillbirth prevention

Background: Stillbirth is a devastating pregnancy outcome that affects approximately 3.5 per 1000 births in high-income countries. Previous research has highlighted the importance of focusing prevention efforts on targeting risk factors and vulnerable groups. A wide range of risk factors has been associated with stillbirth before, including maternal behaviours such as back sleep position, smoking, alcohol intake, illicit drug use, and inadequate attendance at antenatal care. Given the modifiable nature of these risk factors, there has been an increase in the design of behaviour change interventions targeting such behaviours to reduce the risk of stillbirth. Objectives: The aim of this study is to identify all behavioural interventions with a behavioural component designed and trialled for the prevention of stillbirth in high-income countries, and to identify the behaviour change techniques (BCTs) used in such interventions using the Behaviour Change Techniques Taxonomy V1 (BCTTv1). Inclusion criteria: Interventions will be included in this review if they (1) have the objective of reducing stillbirth rates with a focus on behavioural risk factors; (2) are implemented in high-income countries; (3) target pregnant women or women of childbearing age; and (4) are published in research articles. Methods: A systematic search of the literature will be conducted. The results of the search will be screened against our inclusion criteria by two authors. The following data items will be extracted from the selected papers: general information, study characteristics, participant and intervention/approach details. The Cochrane Effective Practice and Organization of Care (EPOC) risk of bias criteria will be used to assess the methodological quality of included studies. Intervention content will be coded for BCTs as present (+) or absent (-) by two authors using the BCTTv1, discrepancies will be discussed with a third author. A narrative synthesis approach will be used to present the results of this systematic review.

A protocol for a systematic review of behaviour change techniques used in the context of stillbirth prevention

Background: Stillbirth is a devastating pregnancy outcome that affects approximately 3.5 per 1000 births in high-income countries. Previous research has highlighted the importance of focusing prevention efforts on targeting risk factors and vulnerable groups. A wide range of risk factors has been associated with stillbirth before, including maternal behaviours such as back sleep position, smoking, alcohol intake, illicit drug use, and inadequate attendance at antenatal care. Given the modifiable nature of these risk factors, there has been an increase in the design of behaviour change interventions targeting such behaviours to reduce the risk of stillbirth. Objectives: The aim of this study is to identify all behavioural interventions with a behavioural component designed and trialled for the prevention of stillbirth in high-income countries, and to identify the behaviour change techniques (BCTs) used in such interventions using the Behaviour Change Techniques Taxonomy V1 (BCTTv1). Inclusion criteria: Interventions will be included in this review if they (1) have the objective of reducing stillbirth rates with a focus on behavioural risk factors; (2) are implemented in high-income countries; (3) target pregnant women or women of childbearing age; and (4) are published in research articles. Methods: A systematic search of the literature will be conducted. The results of the search will be screened against our inclusion criteria by two authors. The following data items will be extracted from the selected papers: general information, study characteristics, participant and intervention/approach details. The Cochrane Effective Practice and Organization of Care (EPOC) risk of bias criteria will be used to assess the methodological quality of included studies. Intervention content will be coded for BCTs as present (+) or absent (-) by two authors using the BCTTv1, discrepancies will be discussed with a third author. A narrative synthesis approach will be used to present the results of this systematic review.

Women with a predisposition for diabetes have an increased risk of pregnancy complications, especially in combination with pregestational overweight

BACKGROUND

Overweight and gestational diabetes are risk factors for pregnancy complications. We hypothesized that the metabolic impact of overweight on pregnancy outcome, would be different if it was combined with a predisposition for diabetes. The aim of this study was to compare the outcome of pregnancies in women with diabetes diagnosed later in life, to the outcome of pregnancies of women who did not develop diabetes.

METHODS

Women in a population-based cohort who also were registered in the Swedish Medical Birth Registry (n = 4738) were included. A predisposition for diabetes (GDM or diabetes after pregnancy) was found in 455 pregnancies. The number of pregnancies with maternal BMI ≥ 25 kg/m2 and without diabetes were 2466, and in 10,405 pregnancies the mother had a BMI < 25 kg/m2 without diabetes at any time. Maternal BMI, gestational length, gestational weight gain, frequency of caesarean section, infant birth weight, frequency of large for gestational age (LGA) and Apgar score were retrospectively compared.

RESULTS

Pregnancies with normal maternal BMI ≤25 kg/m2, with predisposition for diabetes had a higher frequency of LGA (11.6% vs. 2.9%; p < 0.001), a higher frequency of macrosomia (28.6% vs. 17.6%; p < 0.001), and a shorter gestational length (39.7 vs. 40 weeks; p = 0.08) when compared to pregnancies in women without a predisposition for diabetes. In addition, pregnancies with both maternal predisposition for diabetes and BMI ≥ 25 kg/m2 there was a higher frequency of LGA (23.3% vs. 7.1%; p < 0.001), caesarean section (24.0% vs. 14.9%, p = 0.031) compared to pregnancies in women who were only overweight. A predisposition for diabetes significantly increases the risk of macrosomia (OR1.5; 95% CI 1.07-2.15; p = 0.02).

CONCLUSIONS

In pregnancy, there is an increased frequency of LGA, macrosomia and caesarean section if the woman has a predisposition for diabetes. The frequency of overweight young women is increasing, and it is urgent to identify pregnant women with a predisposition to diabetes. How to distinguish the women with the highest risk for adverse pregnancy outcome and the highest risk of future disease, remains to be studied.

Fetal adrenal gland size in gestational diabetes mellitus

Background The aim of this study was to compare the adrenal gland size of fetuses of women with gestational diabetes mellitus (GDM) with that of healthy control fetuses. Methods This prospective cross-sectional study included measurements of the adrenal gland size of 62 GDM fetuses (GDM group) and 370 normal controls (control group) between the 19th and 41st week of gestation. A standardized transversal plane was used to measure the total width and the medulla width. The cortex width and an adrenal gland ratio (total width/medulla width) were calculated from these data. Adrenal gland size measurements were adjusted to the week of gestation and compared between the two groups in a multivariable linear regression analysis. A variance decomposition metric was used to compare the relative importance of predictors of the different adrenal gland size measurements. Results For all the investigated parameters of the adrenal gland size, increased values were found in the case of GDM (P < 0.05), while adjusting for the week of gestation. GDM seems to have a greater impact on the size of the cortex than on the size of the medulla. Conclusion The fetal adrenal gland is enlarged in pregnancy complicated by GDM. The width of the cortex seems to be particularly affected.

Risk factors and classification of stillbirth in a Middle Eastern population: a retrospective study

OBJECTIVE

To estimate the incidence of stillbirth, explore the associated maternal and fetal factors and to evaluate the most appropriate classification of stillbirth for a multiethnic population.

METHODS

This is a retrospective population-based study of stillbirth in a large tertiary unit. Data of each stillbirth with a gestational age >/=24 weeks in the year 2015 were collected from electronic medical records and analyzed.

RESULTS

The stillbirth rate for our multiethnic population is 7.81 per 1000 births. Maternal medical factors comprised 52.4% in which the rates of hypertensive disorders, diabetes and other medical disorders were 22.5%, 20.8% and 8.3%, respectively. The most common fetal factor was intrauterine growth restriction (IUGR) (22.5%) followed by congenital anomalies (21.6%). All cases were categorized using the Wigglesworth, Aberdeen, Tulip, ReCoDe and International Classification of Diseases-perinatal mortality (ICD-PM) classifications and the rates of unclassified stillbirths were 59.2%, 46.6%, 16.6%, 11.6% and 7.5%, respectively. An autopsy was performed in 9.1% of cases reflecting local religious and cultural sensitivities.

CONCLUSION

This study highlighted the modifiable risk factors among the Middle Eastern population. The most appropriate classification was the ICD-PM. The low rates of autopsy prevented a detailed evaluation of stillbirths, therefore it is suggested that a minimally invasive autopsy [postmortem magnetic resonance imaging (MRI)] may improve the quality of care.

Measuring fetal thymus size: a new method for diabetes screening in pregnancy

Objective: To investigate the correlation between fetal thymus size and diabetes in pregnancy.Method: Fetal thymus size was assessed in 160 pregnant women with gestational age of 19-39 weeks. They included 80 diabetic (investigation group) and 80 nondiabetic (control group) women. Fetal thymus size was measured by thymic-thoracic ratio. We did this with dividing the thymus' anteroposterior diameter by anteroposterior of mediastinum.Results: Thymic-thoracic ratio was significantly smaller in fetuses of diabetic mothers compared to the nondiabetic group (p = .001). It remained significant after subgrouping diabetic mothers into overt diabetes, insulin-dependent gestational diabetes, and noninsulin-dependent gestational diabetes.Conclusion: Although thymus size was smaller in fetuses of diabetic pregnant women compared to nondiabetic pregnant women, it seems that thymic-thoracic ratio can be a predictor of diabetes and its other related adverse effects during pregnancy.

Prevalence and risk factors of gestational diabetes mellitus: findings from a universal screening feasibility program in Lima, Peru

Background

Gestational diabetes mellitus (GDM) is a global public health concern with potential implications for the health of a mother and her offspring. However, data on the prevalence and risk factors of GDM in Latin America are scarce.

The study was designed to estimate the prevalence of GDM and identify maternal risk factors among Peruvian women.

Methods

A cross-sectional study was conducted among 1300 pregnant women attending a prenatal clinic in Lima, Peru. GDM was diagnosed using an Oral Glucose Tolerance Test (OGTT) performed between 24 and 28 gestational weeks using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria. Depression status was assessed using the Patient Health Questionnaire-9. Multivariate logistic regression models were used to identify risk factors of GDM.

Results

Approximately 16% of pregnant women were diagnosed with GDM. The prevalence of obesity and depression were 24.4 and 10.6%, respectively. After adjusting for confounders, mid-pregnancy obesity was associated with a 1.64-fold increased odds of GDM (OR: 1.64; 95% CI: 1.03–2.61). Participants with a family history of diabetes had a 1.5-fold increased odds of developing GDM (OR: 1.51, 95% CI: 1.10–2.07) as compared to women without this family history. Depression was associated with a 1.54-fold increased odds of GDM (OR: 1.54; 95% CI:1.09–2.17).

Conclusions

GDM is highly prevalent and was associated with maternal obesity, family history of diabetes and antepartum depression among Peruvian women. Intervention programs aimed at early diagnoses and management of GDM need to take maternal obesity, family history of diabetes and antepartum depression into account.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1904-0) contains supplementary material, which is available to authorized users.

Fetal thymus size in pregnant women with diabetic diseases

AIM

The aim of our study was to assess fetal thymus size in diabetic pregnancies compared with normal pregnancies.

METHODS

Sonographic fetal thymus size was retrospectively assessed in 161 pregnancies with maternal diabetes and in 161 uncomplicated pregnancies matched by gestational age. The anteroposterior thymic and the intrathoracic mediastinal diameter were measured and the quotient was calculated [thymic-thoracic ratio (TT-ratio)]. In addition, we defined the quotient of the anteroposterior thymic diameter and the head circumference as thymus-head ratio (TH-ratio). The maternal diabetes cases were subdivided into three groups: (1) diet-controlled gestational diabetes, (2) insulin-dependent gestational diabetes and (3) preexisting maternal diabetes.

RESULTS

TT-ratio and TH-ratio were smaller in pregnancies with maternal diabetes (P<0.001 and P<0.001, respectively). In all three maternal diabetes subgroups, the TT-ratio and the TH-ratio were lower compared with the control group (P<0.001 for each group).

CONCLUSIONS

Reduced fetal thymus size seems to be associated with diabetic pregnancy. We introduce fetal thymus size as a new potential prognostic parameter for maternal diabetes.

Exposure to pistachio pesticides and stillbirth: a case-control study

OBJECTIVES

Stillbirth is an undesirable outcome of pregnancy. In light of the increasing use of pesticides and growing concerns about the possible health effects of agricultural pesticides, we investigated the effect of exposure to pistachio pesticides on stillbirth in pregnant mothers.

METHODS

This case-control study was conducted in Rafsanjan, Iran from 2011 to 2012. A total of 125 females who had a recent stillbirth were included as the case group, and 250 controls were selected from females who had a recent live birth. For each case, two controls with the nearest propensity score to the case were selected. Data were collected using a protocol developed by the researcher that involved interviewing respondents and reviewing their medical records. Conditional multivariate and univariate logistic regression analysis were performed and odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

The ORs of stillbirth in mothers living in pistachio gardens and those who were exposed to sprayed pesticides, in comparison to the controls, were 14.1 (95% CI, 3.3 to 63.4) and 5.0 (95% CI, 1.2 to 28.6), respectively. No significant differences were found in stillbirth rates according to the distance between the mother's residence and a pistachio garden or involvement in agricultural activities.

CONCLUSIONS

The results of our study showed that exposure to pistachio pesticides during pregnancy may increase the likelihood of stillbirth in mothers.

Early adolescent Depo-Provera exposure increases stillbirths in adult sooty mangabeys

The 3-month injectable contraceptive medroxyprogesterone acetate (MPA; Depo-Provera) is a synthetic progestin that protects against pregnancy by suppressing ovulation. Studies have focused on the resumption of ovulation after MPA-treatment cessation but neglected potential long-term effects of MPA exposure on future successful reproduction. MPA is frequently administered to adolescent girls; however, long-term fertility effects of adolescent MPA exposure have not been explored. We investigated fertility after extended MPA exposure in a species of old world primate, the sooty mangabey (Cercocebus atys). Female sooty mangabeys (n=31) received chronic MPA-treatment for 4–8 years. At MPA-treatment onset, subjects were either parous adults (n=14) or nulliparous adolescents (n=17), with adolescent-treated subjects being further divided into those who had reached first ovulation (n=10) and those who had not (n=7). After MPA-treatment cessation, adolescent-treated females had a significantly higher incidence of stillbirth than did age-matched and parity-matched controls, whereas adult-treated females did not differ from their matched controls. Females placed on MPA-treatment prior to first ovulation had a significantly higher incidence of stillbirth post-treatment than did females placed on MPA-treatment after first ovulation. Diabetic females had an increased incidence of stillbirth as compared to nondiabetic females; however, when controlling for diabetes, MPA exposure prior to first ovulation was still a significant positive predictor of stillbirth. These findings suggest that the post-treatment fertility effects of chronic MPA exposure vary with the developmental timing of treatment onset and raise concern about the use of MPA as a contraceptive for adolescent girls.

Stillbirth in the pregnancy complicated by diabetes

Pregestational diabetes currently complicates 4% of pregnancies, while gestational diabetes complicates approximately 8% of pregnancies. Increased risk of stillbirth in diabetic pregnancies has been a well-known and recognized complication for decades. While stillbirth rates for diabetic pregnancies have decreased due to screening, treatment, and antenatal surveillance of these patients, about 4% of all stillbirths remain attributable to diabetes, and diabetic pregnancies continue to be at increased risk for perinatal mortality. The purpose of this article is to review the literature on the epidemiology, pathophysiology, and prevention, as well as future research, of diabetes-associated perinatal mortality.

Pre-existing diabetes, maternal glycated haemoglobin, and the risks of fetal and infant death: a population-based study

AIMS/HYPOTHESIS

Pre-existing diabetes is associated with an increased risk of stillbirth, but few studies have excluded the effect of congenital anomalies. This study used data from a long-standing population-based survey of women with pre-existing diabetes to investigate the risks of fetal and infant death and quantify the contribution of glycaemic control.

METHODS

All normally formed singleton offspring of women with pre-existing diabetes (1,206 with type 1 diabetes and 342 with type 2 diabetes) in the North of England during 1996-2008 were identified from the Northern Diabetes in Pregnancy Survey. RRs of fetal death (≥20 weeks of gestation) and infant death were estimated by comparison with population data from the Northern Perinatal Morbidity and Mortality Survey. Predictors of fetal and infant death in women with pre-existing diabetes were examined by logistic regression.

RESULTS

The prevalence of fetal death in women with diabetes was over four times greater than in those without (RR 4.56 [95% CI 3.42, 6.07], p < 0.0001), and for infant death it was nearly doubled (RR 1.86 [95% CI 1.00, 3.46], p = 0.046). There was no difference in the prevalence of fetal death (p = 0.51) or infant death (p = 0.70) between women with type 1 diabetes and women with type 2 diabetes. There was no evidence that the RR of fetal and infant death had changed over time (p = 0.95). Increasing periconception HbA1c concentration above 49 mmol/mol (6.6%) (adjusted odds ratio [aOR] 1.02 [95% CI 1.00, 1.04], p = 0.01), prepregnancy retinopathy (aOR 2.05 [95% CI 1.04, 4.05], p = 0.04) and lack of prepregnancy folic acid consumption (aOR 2.52 [95% CI 1.12, 5.65], p = 0.03) were all independently associated with increased odds of fetal and infant death.

CONCLUSIONS/INTERPRETATION

Pre-existing diabetes is associated with a substantially increased risk of fetal and infant death in normally formed offspring, the effect of which is largely moderated by glycaemic control.

Maternal hyperglycemia and adverse pregnancy outcomes in Dar es Salaam, Tanzania

OBJECTIVE

To evaluate maternal glucose levels during pregnancy as a predictor of adverse perinatal outcomes in Dar es Salaam, Tanzania.

METHODS

Random blood glucose measurements were analyzed from 3383 pregnant women enrolled in a randomized trial to assess the impact of multivitamins on pregnancy outcomes in Dar es Salaam between August 2001 and July 2004. Information on maternal and neonatal morbidity was recorded at monthly study visits, delivery, and 6 weeks postpartum. Binomial regression and generalized estimating equations were used to determine the relationship between elevated glucose (>7.8 mmol/L) and pregnancy outcomes.

RESULTS

In total, 25 women had elevated glucose (0.7%). Hyperglycemia was associated with an increased risk of delivery before 37 weeks [relative risk (RR), 2.11; 95% confidence interval [CI], 1.07-4.13; P=0.03), delivery before 34 weeks (RR, 4.15; 95% CI, 1.43-12.03, P=0.009), incident gestational hypertension (RR, 2.90; 95% CI, 1.24-6.76; P=0.01), low birth weight (RR, 2.87; 95% CI, 1.18-6.99; P=0.02), reduced newborn head circumference (mean difference, -1.57; 95% CI, -2.51 to -0.62; P=0.001), and fetal loss (RR, 3.38; 95% CI, 1.13-10.08; P=0.03).

CONCLUSION

Maternal hyperglycemia is uncommon among pregnant Tanzanian women, but nonetheless seems to increase the risk of several adverse perinatal outcomes.

Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis

BACKGROUND

Stillbirth rates in high-income countries have shown little or no improvement over the past two decades. Prevention strategies that target risk factors could be important in rate reduction. This systematic review and meta-analysis was done to identify priority areas for stillbirth prevention relevant to those countries.

METHODS

Population-based studies addressing risk factors for stillbirth were identified through database searches. The factors most frequently reported were identified and selected according to whether they could potentially be reduced through lifestyle or medical intervention. The numbers attributable to modifiable risk factors were calculated from data relating to the five high-income countries with the highest numbers of stillbirths and where all the data required for analysis were available. Odds ratios were calculated for selected risk factors, from which population-attributable risk (PAR) values were calculated.

FINDINGS

Of 6963 studies initially identified, 96 population-based studies were included. Maternal overweight and obesity (body-mass index >25 kg/m(2)) was the highest ranking modifiable risk factor, with PARs of 8-18% across the five countries and contributing to around 8000 stillbirths (≥22 weeks' gestation) annually across all high-income countries. Advanced maternal age (>35 years) and maternal smoking yielded PARs of 7-11% and 4-7%, respectively, and each year contribute to more than 4200 and 2800 stillbirths, respectively, across all high-income countries. In disadvantaged populations maternal smoking could contribute to 20% of stillbirths. Primiparity contributes to around 15% of stillbirths. Of the pregnancy disorders, small size for gestational age and abruption are the highest PARs (23% and 15%, respectively), which highlights the notable role of placental pathology in stillbirth. Pre-existing diabetes and hypertension remain important contributors to stillbirth in such countries.

INTERPRETATION

The raising of awareness and implementation of effective interventions for modifiable risk factors, such as overweight, obesity, maternal age, and smoking, are priorities for stillbirth prevention in high-income countries.

FUNDING

The Stillbirth Foundation Australia, the Department of Health and Ageing, Canberra, Australia, and the Mater Foundation, Brisbane, Australia.

Effect of screening and management of diabetes during pregnancy on stillbirths

BACKGROUND

Diabetes during pregnancy is associated with significant risk of complications to the mother, fetus and newborn. We reviewed the potential impact of early detection and control of diabetes mellitus during pregnancy on stillbirths for possible inclusion in the Lives Saved Tool (LiST).

METHODS

A systematic literature search up to July 2010 was done to identify all published randomized controlled trials and observational studies. A standardized data abstraction sheet was employed and data were abstracted by two independent authors. Meta-analyses were performed with different sub-group analyses. The analyses were graded according to the CHERG rules using the adapted GRADE criteria and recommendations made after assessing the overall quality of the studies included in the meta-analyses.

RESULTS

A total of 70 studies were selected for data extraction including fourteen intervention studies and fifty six observational studies. No randomized controlled trials were identified evaluating early detection of diabetes mellitus in pregnancy versus standard screening (glucose challenge test between 24th to 28th week of gestation) in pregnancy. Intensive management of gestational diabetes (including specialized dietary advice, increased monitoring and tailored dietary therapy) during pregnancy (3 studies: 3791 participants) versus conventional management (dietary advice and insulin as required) was associated with a non-significant reduction in the risk of stillbirths (RR 0.20; 95% CI: 0.03-1.10) ('moderate' quality evidence). Optimal control of serum blood glucose versus sub-optimal control was associated with a significant reduction in the risk of perinatal mortality (2 studies, 5286 participants: RR = 0.40, 95% CI 0.25- 0.63), but not stillbirths (3 studies, 2469 participants: RR = 0.51, 95% CI 0.14-1.88). Preconception care of diabetes (information about need for optimization of glycemic control before pregnancy, assessment of diabetes complications, review of dietary habits, intensification of capillary blood glucose self-monitoring and optimization of insulin therapy) versus none (3 studies: 910 participants) was associated with a reduction in perinatal mortality (RR = 0.29, 95% CI 0.14 -0.60). Using the Delphi process for estimating effect size of optimal diabetes recognition and management yielded a median effect size of 10% reduction in stillbirths.

CONCLUSIONS

Diabetes, especially pre-gestational diabetes with its attendant vascular complications, is a significant risk factor for stillbirth and perinatal death. Our review highlights the fact that very few studies of adequate quality are available that can provide estimates of the effect of screening for aid management of diabetes in pregnancy on stillbirth risk. Using the Delphi process we recommend a conservative 10% reduction in the risk of stillbirths, as a point estimate for inclusion in the LiST.

A multicenter, case-control study on risk factors for antepartum stillbirth

OBJECTIVE

As the influence of socio-demographic variables, lifestyle and medical conditions on the epidemiology of stillbirth (SB) is modified by population features, we aimed at investigating the role played by these factors on the incidence of SB in a developed country.

STUDY DESIGN

Multivariate logistic regression analysis (OR with 95% CI) was utilized in a prospective multicentre nested case-control study to compare in a 1:2 ratio stillborn of >22 weeks gestation with matched for gestational age live-born (LB) infants. Intrapartum SB were excluded.

RESULTS

Two hundred fifty-four consecutive SBs and 497 LBs were enrolled. Socio-demographic variables were equally distributed. Fetal malformations (7.96, 2.69-23.55), severe intrauterine growth restriction (IUGR) (birthweight ≤ 5(th) %ile) (4.32, 2.27?8.24), BMI > 25 (2.87, 1.90-4.33), and preeclampsia (PE, 0.40, 0.21-0.77) were recognized as independent predictors for SB. At term, only BMI > 25 was associated with SB (7.70, 2.9-20.5).

CONCLUSION

Fetal malformations, severe IUGR and maternal BMI > 25 were associated with a significant increase in the risk of SB; PE presented instead a protective role. Maternal BMI > 25 was the only risk factor for SB identified in term pregnancies.

Male sex and pre-existing diabetes are independent risk factors for stillbirth

AIM

To determine whether the risk of stillbirth is associated with male fetal sex, fetal growth and maternal factors in an Australian population.

METHODS

A retrospective secondary data analysis of 16 445 singleton births was performed using a tertiary referral centre obstetric database (1995-1999). Univariate and multiple logistic regression analyses were performed.

RESULTS

Stillbirth complicated 1% of the pregnancies in the study population, and 59% of stillbirths were associated with a male fetus. Significant characteristics associated with stillbirth were intrauterine growth restriction (IUGR), birth defects, gestational age, Aboriginal ethnicity, previous stillbirth, parity greater than three and placental abruption. Male stillbirths were more likely to occur at a later gestation (median gestation 30.5 weeks, range 20-43 weeks) compared to females (median 25 weeks, range 20-40 weeks), P = 0.01. Sixty per cent of IUGR fetuses were female (P < 0.001). Male sex (odds ratio (OR) 1.5, confidence interval (CI) 1.01, 2.17, P = 0.04) and maternal type 1 diabetes (OR 4.7, CI 1.58, 14.19, P = 0.006) were independently associated with stillbirth.

CONCLUSION

Male fetal sex and pre-existing diabetes are independent risk factors for stillbirth. Diabetes remains a significant risk for stillbirth even with contemporary monitoring and clinical management. Those diabetic pregnancies where the fetus is male require appropriate monitoring and timely interventions to achieve an optimal outcome.

Diabetic-associated stillbirth: incidence, pathophysiology, and prevention

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.

Diabetic-associated stillbirth: incidence, pathophysiology, and prevention

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.

A comprehensive analysis of adverse obstetric and pediatric complications in women with asthma

RATIONALE

Previous studies have raised concern that women with asthma have increased risks of adverse obstetric and pediatric complications, but these have generally been underpowered.

OBJECTIVES

To quantify risks of major adverse pregnancy outcomes and obstetric complications in women with and without asthma.

METHODS

We extracted information on 281,019 pregnancies from the Health Improvement Network database between 1988 and 2004. We analyzed the data using logistic regression.

MEASUREMENTS AND MAIN RESULTS

In 37,585 pregnancies of women with asthma compared with 243,434 pregnancies of women without asthma, risks of stillbirth and therapeutic abortion were similar; however, the risk of miscarriage was slightly higher (odds ratio [OR], 1.10; 95% confidence interval [CI], 1.06-1.13). Risks of most obstetric complications (placental abruption, placental insufficiency, placenta previa, preeclampsia, hypertension, gestational diabetes, thyroid disorders in pregnancy, and assisted delivery) were not higher in pregnancies of women with asthma compared with those without asthma, with the exception of increases in antepartum (OR, 1.20; 95% CI, 1.08-1.34) or postpartum (OR, 1.38; 95% CI, 1.21-1.57) hemorrhage, anemia (OR, 1.06; 95% CI, 1.01-1.12), depression (OR, 1.52; 95% CI, 1.36-1.69), and caesarean section (OR, 1.11; 95% CI, 1.07-1.16). Risks of miscarriage, depression, and caesarean section increased moderately in women with more severe asthma and previous asthma exacerbations.

CONCLUSIONS

We found some increased risks in women with asthma that need to be considered in the future; however, our results indicate that women with asthma have similar reproductive risks compared with women without asthma in the general population for most of the range of outcomes studied.

All-cause mortality rates in patients with type 1 diabetes mellitus compared with a non-diabetic population from the UK general practice research database, 1992-1999

AIMS/HYPOTHESIS

We compiled up to date estimates of the absolute and relative risk of all-cause mortality in patients with type 1 diabetes in the UK.

MATERIALS AND METHODS

We selected patients with type 1 diabetes (n=7,713), and for each of these diabetic subjects five age- and sex-matched control subjects without diabetes (n=38,518) from the General Practice Research Database (GPRD). Baseline was 1 January 1992; subjects were followed until 1999. The GPRD is a large primary-care database containing morbidity and mortality data of a large sample representative of the UK population. Deaths occurring in the follow-up period were identified.

RESULTS

The study comprised 208,178 person-years of follow-up. The prevalence of type 1 diabetes was 2.15/1,000 subjects in 1992 (mean age 33 years, SD 15). Annual mortality rates were 8.0 per 1,000 person-years (95% CI 7.2-8.9) in type 1 diabetic subjects compared with 2.4 per 1,000 person-years (95% CI 2.2-2.6) in those without diabetes (hazard ratio [HR]=3.7, 95% CI 3.2-4.3). The increased mortality rates in patients with type 1 diabetes were apparent across all age-bands. The HR was higher in women (HR=4.5, 95% CI 3.5-5.6 compared with non-diabetic women) than men (HR=3.3, 95% CI 2.7-4.0), such that the sex difference (p<0.0001) in mortality in the non-diabetic population was abolished (p=0.3) in the type 1 diabetic patients. The predominant cause of death in patients with type 1 diabetes was cardiovascular disease.

CONCLUSIONS/INTERPRETATION

Despite advances in care, UK mortality rates in the past decade continue to be much greater in patients with type 1 diabetes than in those without diabetes.

Fertility and pregnancy-related events in women with celiac disease: a population-based cohort study

BACKGROUND & AIMS

Previous studies have raised concern about reduced fertility and increased adverse pregnancy-related events in women with celiac disease, but none has estimated overall fertility compared with the general female population.

METHODS

We compared computerized primary care data for 1521 women with celiac disease with data for 7732 age- and practice-matched women without celiac disease. We estimated population-based rates of fertility and adverse pregnancy outcomes.

RESULTS

Crude fertility rates were 48.2 and 47.7 live births per 1000 person-years for women with and without celiac disease, respectively (rate ratio, 1.01; 95% confidence interval, 0.90-1.14). Age-specific fertility rates showed that women with celiac disease had lower fertility when younger but higher fertility when older compared with women without celiac disease. This increase in relative fertility with increasing age held whether women had treated or untreated celiac disease. Risks of cesarean section (odds ratio, 1.33; 95% confidence interval, 1.03-1.70) and miscarriage (rate ratio, 1.31; 95% confidence interval, 1.06-1.61) were moderately higher in women with celiac disease, but risks of assisted birth, breech birth, preeclampsia, postpartum hemorrhage, ectopic pregnancy, stillbirth, and termination were similar.

CONCLUSIONS

Overall, women with celiac disease have fertility similar to that of the general female population, but they have their babies at an older age. Although our findings may reflect a disease effect, the age shift in fertility rates and the increase in cesarean section risk is consistent with socioeconomic or educational advantages of women with celiac disease.