Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Rochester Medical Center, Rochester, NY, USA.
Department of Clinical and Translational Research, Department of Obstetrics and Gynecology, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA.
J Matern Fetal Neonatal Med. 2022 Jun;35(11):2091-2098. doi: 10.1080/14767058.2020.1779213. Epub 2020 Jun 21.
Diabetes in pregnancy is associated with an increased rate of stillbirth. There are a wide variety of factors that have been implicated including placental insufficiency, hypoxia, hyperinsulinemia and impaired cardiac function. Furthermore, there is evidence that diabetic pregnancies have an increased rate of fetal cardiomyopathy as compared to non-diabetic pregnancies. Prior studies have indicated that this association can also be an etiology for diabetic stillbirth. The purpose of this study was to determine if diabetic pregnancies have an increased risk of fetal cardiomyopathy identified on fetal autopsy as compared to non-diabetic women with a stillbirth in a cohort of pregnancies that had evaluation with a fetal autopsy.
Retrospective cohort study of women with a stillbirth who consented to fetal autopsy at an academic medical center from 2011 to 2017. Stillbirth was defined as an intrauterine fetal demise at ≥20 weeks' gestation. Women with diabetes defined as pre-gestational diabetes type 1, pre-gestational diabetes type 2, and gestational diabetes were compared to women without diabetes. Primary outcome was fetal cardiomyopathy. Other etiologies for stillbirth were also evaluated and classified according to the Stillbirth Collaborative Research Network (SCRN) initial causes of fetal death. Fisher exact test, χ2 test, and Mann Whitney U tests were performed as appropriate, with < .05 considered significant. Generalized linear models were performed for fetal organ weights controlling for gestational age of delivery, maternal chronic hypertension, delivery body mass index, and birthweight.
A total of 78 women elected to have fetal autopsy examinations during the study period. Of these, 75 had complete information available for review. A total of 60 women did not have diabetes and 15 women had diabetes. Of pregnancies complicated by diabetes, 11 had insulin dependent diabetes and 4 had non-insulin dependent diabetes. Fetal cardiomyopathy was diagnosed on autopsy for 7 (46.7%) of pregnancies with diabetes and 2 (3.3% of pregnancies without diabetes (RR 14.00 [95% CI 3.23-60.65], < .001). These associations were still significant even when analyzing only those pregnancies without fetal congenital heart disease (7 [46.7%] diabetic pregnancies with cardiomyopathy versus 1 [2.0%] nondiabetic pregnancy with cardiomyopathy, RR 23.80 [95% CI 3.17-178.46], < .001). There was no difference between diabetic and non-diabetic pregnancies in regards to other causes for stillbirth. Stillbirths in pregnancies with diabetes also had larger fetal heart, liver, and adrenal weights on fetal autopsy.
Women with diabetes have 14 times the risk of fetal cardiomyopathy identified at fetal autopsy as compared to women without diabetes. As the prediction and prevention of diabetic stillbirth is limited, information on potential causes of stillbirth may help future research identify those pregnancies at the greatest risk for adverse outcome.
妊娠糖尿病与死胎发生率增加有关。有许多因素与之相关，包括胎盘功能不全、缺氧、高胰岛素血症和心功能障碍。此外，有证据表明，与非糖尿病孕妇相比，糖尿病孕妇的胎儿心肌病发生率更高。先前的研究表明，这种关联也可能是糖尿病死胎的病因之一。本研究旨在确定与非糖尿病孕妇相比，在接受胎儿尸检的妊娠队列中，糖尿病孕妇的胎儿心肌病风险是否增加。
对 2011 年至 2017 年在学术医疗中心同意接受胎儿尸检的死胎女性进行回顾性队列研究。死胎定义为 20 周以上宫内胎儿死亡。糖尿病定义为孕前 1 型糖尿病、孕前 2 型糖尿病和妊娠期糖尿病，与无糖尿病的女性进行比较。主要结局为胎儿心肌病。还根据胎儿死亡协作研究网络（SCRN）的初始病因评估了其他死胎病因，并进行分类。Fisher 确切检验、χ2 检验和 Mann Whitney U 检验适用于不同情况， < .05 为差异有统计学意义。控制分娩时的胎龄、产妇慢性高血压、分娩体重指数和出生体重，对胎儿器官重量进行广义线性模型分析。
在研究期间，共有 78 名女性选择进行胎儿尸检检查。其中，75 名女性有完整的信息可供审查。共有 60 名女性没有糖尿病，15 名女性患有糖尿病。患有糖尿病的孕妇中，11 名胰岛素依赖型糖尿病，4 名非胰岛素依赖型糖尿病。尸检诊断为 7 例（糖尿病孕妇的 46.7%）胎儿心肌病和 2 例（非糖尿病孕妇的 3.3%）（RR 14.00 [95% CI 3.23-60.65]， < .001）。即使在仅分析无胎儿先天性心脏病的孕妇时，这些关联仍然具有统计学意义（糖尿病孕妇中有 7 例（46.7%）患有心肌病与无糖尿病孕妇中有 1 例（2.0%）患有心肌病，RR 23.80 [95% CI 3.17-178.46]， < .001）。糖尿病孕妇与非糖尿病孕妇在其他死胎原因方面无差异。糖尿病孕妇的胎儿尸检还显示胎儿心脏、肝脏和肾上腺的重量更大。
与无糖尿病孕妇相比，糖尿病孕妇的胎儿心肌病发生率高 14 倍。由于对糖尿病性死胎的预测和预防有限，有关潜在死胎原因的信息可能有助于未来的研究确定那些最有可能发生不良结局的孕妇。
