Abstract
Aims/hypothesisStillbirth risk is increased in pregnancy complicated by diabetes. Fear of stillbirth has major influence on obstetric management, particularly timing of delivery. We analysed population-level data from Scotland to describe timing of stillbirths in women with diabetes and associated risk factors.MethodsA retrospective cohort of singleton deliveries to mothers with type 1 (n = 3778) and type 2 diabetes (n = 1614) from 1 April 1998 to 30 June 2016 was analysed using linked routine care datasets. Maternal and fetal characteristics, HbA1c data and delivery timing were compared between stillborn and liveborn groups.ResultsStillbirth rates were 16.1 (95% CI 12.4, 20.8) and 22.9 (95% CI 16.4, 31.8) per 1000 births in women with type 1 (n = 61) and type 2 diabetes (n = 37), respectively. In women with type 1 diabetes, higher HbA1c before pregnancy (OR 1.03 [95% CI 1.01, 1.04]; p = 0.0003) and in later pregnancy (OR 1.06 [95% CI 1.04, 1.08]; p < 0.0001) were associated with stillbirth, while in women with type 2 diabetes, higher maternal BMI (OR 1.07 [95% CI 1.01, 1.14]; p = 0.02) and pre-pregnancy HbA1c (OR 1.02 [95% CI 1.00, 1.04]; p = 0.016) were associated with stillbirth. Risk was highest in infants with birthweights <10th centile (sixfold higher born to women with type 1 diabetes [n = 5 stillbirths, 67 livebirths]; threefold higher for women with type 2 diabetes [n = 4 stillbirths, 78 livebirths]) compared with those in the 10th–90th centile (n = 20 stillbirths, 1685 livebirths). Risk was twofold higher in infants with birthweights >95th centile born to women with type 2 diabetes (n = 15 stillbirths, 402 livebirths). A high proportion of stillborn infants were male among mothers with type 2 diabetes (81.1% vs 50.5% livebirths, p = 0.0002). A third of stillbirths occurred at term, with highest rates in the 38th week (7.0 [95% CI 3.7, 12.9] per 1000 ongoing pregnancies) among mothers with type 1 diabetes and in the 39th week (9.3 [95% CI 2.4, 29.2]) for type 2 diabetes.Conclusions/interpretationMaternal blood glucose levels and BMI are important modifiable risk factors for stillbirth in diabetes. Babies at extremes of weight centiles are at most risk. Many stillbirths occur at term and could potentially be prevented by change in routine care and delivery policies.
Highlights
Mothers with pregestational diabetes are at 4–5-fold increased risk of stillbirth [1], with data from our and other populations showing no improvement in recentDiabetologia (2019) 62:1938–1947 years [1, 2]
Stillbirth rates were 16.1 per 1000 births in type 1 diabetes (n = 61) and 22.9 per 1000 births in type 2 diabetes (n = 37)
In keeping with other studies, we find that maternal blood glucose level is the key modifiable risk factor for adverse perinatal outcomes [6, 15, 16]
Summary
Diabetologia (2019) 62:1938–1947 years [1, 2] This contrasts with decreasing stillbirth rates seen in the general obstetric population [1]. Maternal obesity, advanced maternal age and smoking are important modifiable risk factors for stillbirth in the general obstetric population [3, 4]. Suboptimal maternal blood glucose levels even at minimal levels, presence of microvascular complications and poor preparation for pregnancy are associated with stillbirth [5, 6]. Other traditional risk factors seen in the general obstetric population are less well documented in diabetes. We analysed national data from all deliveries to mothers with pregestational diabetes in Scotland over an 18 year period, to better define maternal and fetal characteristics associated with stillbirth. Timing of stillbirth was analysed to identify potential for population-based strategies around routine delivery
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