Department of Obstetrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
Department for Internal Medicine III, Jena University Hospital, Jena, Germany.
Arch Gynecol Obstet. 2024 Oct;310(4):2015-2021. doi: 10.1007/s00404-024-07609-9. Epub 2024 Jul 3.
Compared to the general stillbirth rate in Germany for term deliveries of 0.12% the risk in type 1 diabetes mellitus is reported to be up to ten times higher. The reasons for this excess risk of intrauterine demise are still not fully elucidated. Risk factors named in the literature include poor glycemic control before and during pregnancy and the occurrence of ketoacidosis. Additionally there might be a diabetes related type of placental dysfunction leading to organ failure in late pregnancy. Understanding the underlying causes is mandatory to develop strategies to reduce the incidences. The Purpose of this publication is to point out the difficulties in prediction of intrauterine death in pregnant type 1 diabetes patients and thus emphasizing the necessity of constant awareness to all caregivers.
We present a case series of four cases of stillbirth that occurred in patients with type 1 diabetes mellitus at our tertiary care obstetric unit during a five-year period.
In all four presented cases the underlying cause of intrauterine demise was different and we could not find a common mechanism or risk profile. Furthermore, established monitoring tools did not become peculiar to raise awareness. We compared our cases to published data. Underlying causes of intrauterine death in type 1 diabetes are discussed in the light of the current literature.
The main risk factors of stillbirth in diabetic pregnancies are high maternal blood glucose levels including pre-conceptional HbA1c and diabetic ketoacidosis. Late acute placental insufficiency are associated with intrauterine death in type 1 diabetes. Despite the elevated risk of near term intrauterine demise there are currently no guidelines on how to monitor pregnancies in type 1 diabetes for fetal distress during the third trimester. Established thresholds for fetal Doppler data indicating fetal distress in normal and growth restricted fetuses may not be applicable for overgrown fetuses. Future research on how to monitor the diabetic fetus needs to be initiated.
与德国足月分娩的一般死胎率 0.12%相比，1 型糖尿病的风险据报道高达十倍。导致这种宫内死亡风险增加的原因仍不完全清楚。文献中提到的危险因素包括妊娠前和妊娠期间血糖控制不佳以及酮症酸中毒的发生。此外，可能存在与糖尿病相关的胎盘功能障碍类型，导致晚期妊娠器官衰竭。了解潜在原因对于制定降低发病率的策略是强制性的。本出版物的目的是指出预测 1 型糖尿病孕妇宫内死亡的困难，并因此强调所有护理人员始终保持警惕的必要性。
我们在五年期间报告了在我们的三级保健产科单位发生的四例 1 型糖尿病患者死胎的病例系列。
在所有提出的四个病例中，宫内死亡的根本原因不同，我们没有发现共同的机制或风险特征。此外，既定的监测工具并没有变得特别引人注目。我们将我们的病例与已发表的数据进行了比较。根据当前文献讨论了 1 型糖尿病中宫内死亡的潜在原因。
糖尿病妊娠中死胎的主要危险因素是包括孕前 HbA1c 和糖尿病酮症酸中毒在内的高母体血糖水平。晚期急性胎盘功能不全与 1 型糖尿病的宫内死亡有关。尽管近足月宫内死亡的风险增加，但目前尚无关于如何监测 1 型糖尿病妊娠中胎儿窘迫的指南。用于指示正常和生长受限胎儿胎儿窘迫的胎儿多普勒数据的既定阈值可能不适用于过度生长的胎儿。需要启动关于如何监测糖尿病胎儿的未来研究。
