Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
School of Medicine, University of Glasgow, Glasgow, UK.
Diabetologia. 2019 Oct;62(10):1938-1947. doi: 10.1007/s00125-019-4943-9. Epub 2019 Jul 29.
AIMS/HYPOTHESIS: Stillbirth 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.
A 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, HbA data and delivery timing were compared between stillborn and liveborn groups.
Stillbirth 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 HbA 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 HbA (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/INTERPRETATION: Maternal 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.
目的/假设：患有糖尿病的孕妇发生死产的风险增加。对死产的恐惧对产科管理有重大影响，尤其是分娩时机。我们分析了来自苏格兰的人群水平数据，以描述糖尿病孕妇的死产时间及其相关危险因素。
对 1998 年 4 月 1 日至 2016 年 6 月 30 日期间患有 1 型（n=3778）和 2 型糖尿病（n=1614）的母亲的单胎分娩进行了回顾性队列研究，使用了相关的常规护理数据集。比较了死产组和活产组的产妇和胎儿特征、糖化血红蛋白数据和分娩时间。
1 型糖尿病孕妇的死产率为 16.1（95%CI 12.4，20.8），2 型糖尿病孕妇的死产率为 22.9（95%CI 16.4，31.8），分别为每 1000 例活产 61 例和 37 例。在 1 型糖尿病孕妇中，妊娠前较高的糖化血红蛋白（OR 1.03[95%CI 1.01，1.04]；p=0.0003）和妊娠后较高的糖化血红蛋白（OR 1.06[95%CI 1.04，1.08]；p<0.0001）与死产相关，而在 2 型糖尿病孕妇中，较高的母体 BMI（OR 1.07[95%CI 1.01，1.14]；p=0.02）和妊娠前糖化血红蛋白（OR 1.02[95%CI 1.00，1.04]；p=0.016）与死产相关。与出生体重在第 10 百分位数至第 90 百分位之间的婴儿（n=20 例死产，1685 例活产）相比，出生体重在第 10 百分位数以下的婴儿（n=5 例死产，67 例活产）的风险高 6 倍，而出生体重在第 95 百分位数以上的婴儿（n=15 例死产，402 例活产）的风险高 2 倍。与活产婴儿相比，2 型糖尿病孕妇中男婴死产的比例较高（81.1% vs 50.5%活产，p=0.0002）。三分之一的死产发生在足月，1 型糖尿病孕妇中最高的发生率在第 38 周（每 1000 例持续妊娠 7.0[95%CI 3.7，12.9]），而 2 型糖尿病孕妇中最高的发生率在第 39 周（9.3[95%CI 2.4，29.2]）。
结论/解释：母亲的血糖水平和 BMI 是糖尿病中死产的重要可改变危险因素。体重百分位数极端的婴儿风险最大。许多死产发生在足月，通过改变常规护理和分娩政策可能会预防这些死产。
