High levels of blood sugar and BMI linked to stillbirth in mothers with diabetes

High maternal blood levels and BMI are risk factors for giving birth to mothers with diabetes, according to a new study in Diabetology (the journal of the European Association for the Study of Diabetes), and babies at the lowest and highest weights are at risk. Mothers with pre-natal diabetes have a four to five times increased risk of childbirth – with no improvement over the past few years, unlike declining death rates seen in the general obstetric population.

Furthermore, the level of the blood sugar of the mother appeared as a key risk for further risk of birth. Overall, while a third of births in mothers with diabetes occur near term and could be influenced by delivery policy, most occur 37 weeks ago and finding better ways to detect babies at risk will be critical.

Maternal obesity, advanced maternal age, and smoking are known to be significant modifiable risk factors for birth in the general population, as is restricted fetal growth. However, data on pregnancies complicated by diabetes are more limited. Previous studies have indicated that suboptimal maternal glucose levels, microvascular complications, and poor preparation for pregnancy are associated with stillbirth in mothers with diabetes. However, traditional risk factors noted in the general population are less well documented for mothers with the disease.

This study, conducted by Dr. Robert Lindsay and Dr. Sharon Mackin, of the Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK, and colleagues, analyzed data from mothers diagnosed with prenatal diabetes to help define maternal and fetal characteristics. . associated with death time. Deadline timing was also analyzed to examine the potential for strategies around routine delivery.

Maternity records obtained from the Scottish Morbidity Record 02 (SMR02) – a database containing clinical information on all birth episodes across Scotland including maternal and child demographics, pregnancy / birth complications – were linked with Scottish Care Diabetes Information (SCI) data ). -Diabetes), a database containing patient demographics and clinical information on diagnostic diagnosis, complications and management. Data on infants delivered at or beyond 24 weeks of April 1998 to June 2016 by SMR02 were linked to SCI Diabetes data, identifying mothers diagnosed with type 1 or 2 diabetes prior to delivery. In accordance with accepted legal definitions, nausea was defined as the birth of a child, at or after 24 weeks of pregnancy, who at the time of delivery did not breathe or showed signs of life.

The study considered various potential risks: maternal blood sugar (based on glycated hemoglobin (HbA1c) measurements taken before and during pregnancy); the mother's BMI, again from measurements taken during routine diabetes clinics. and birth weight and especially whether babies fall into the categories of large for gestational age (LGA) or small for gestational age (SGA) by nature of being within the top or bottom 10% of infants in terms of weight. The 2012 Multiple Privacy Index (SIMD) 2012 score was used to consider material depreciation, with mothers assigned to a geographical area by postal code at the time of delivery – each area having a score based on multiple indicators of material deprivation. To evaluate the potential effects of differences in clinic to clinic care, outcomes related to different site and size of hospital delivery were examined.

The study identified 5392 single babies born to 3847 mothers with diabetes — 3778 babies to 2582 mothers with type 1 diabetes; and 1614 babies to 1265 mothers with type 2 diabetes. Birth rates were 16.1 per 1000 births in type 1 and 22.9 per 1000 births in type 2, compared with 4.9 per 1,000 births in the general population,

Consistent with other studies, the authors found that maternal glucose level is the key modifiable risk factor for death pressure. Women with type 1 diabetes, who have suffered stillbirth, have been shown to have higher average blood glucose levels at all stages of pregnancy. For type 2 diabetes, a different pattern was noted – in that pre-pregnancy blood glucose levels, rather than levels during pregnancy, seemed to be more important predictors of stillbirth.

The authors note that in clinical practice, where intake of blood sugar as part of pre-pregnancy counseling would be particularly important in mothers with type 2 diabetes, the uptake of such counseling is generally lower than in type 1 diabetes. They suggest that "overall efforts to improve blood glucose levels before and during pregnancy remain central." Another risk factor for birth in mothers with type 2 diabetes was high maternal BMI. Maternal obesity, the authors note, is itself an independent risk factor for childbirth, contributing to higher rates of preeclampsia, congenital abnormalities and fetal predominance.

In the general obstetric population, the restriction of fetal growth by which the unborn baby is smaller than it should be is the strongest indicator of death pressure. Also in the present study, absolute risk of birth was highest in SGA infants (younger than gestational age), especially for type 1 diabetes. Similarly, LGA babies (older than gestational age) are at risk for the general population as well, and for type 2 diabetes this finding has been mirrored here. Fetal stress is related to maternal hyperglycemia in later pregnancy. In this study, it was found that even for mothers with the lowest blood glucose, the birth weight of the child was considerably higher than that of the general population.

Optimal timing of delivery in diabetes remains controversial, the authors note. Many medical authorities recommend routine early delivery to mothers with diabetes – recent NICE (National Institute for Health and Care) guidelines in England, for example, suggest delivery in the 37th or 38th week. Compared with the general population, an increased risk of birth for women with diabetes is seen in all stages of pregnancy, but previous studies have shown that full-time, the risk is at least five times higher. In this study one third of the offspring were born prematurely. "It would appear then that earlier delivery would be a sensible approach," the authors say. "However, due to potential problems with early birth – including respiratory syndrome resulting from inadequate lung development – we suggest that the increased risk of unborn baby should be more formally investigated before recommendations for optimal timing of delivery, particularly where mothers are successful get almost normal glucose levels. "

Unexpectedly, within this study a high proportion of stillbirths (81%) were male among mothers with type 2 diabetes. Previous studies indicate that male fetuses are more vulnerable in utero, with an increased risk of birth of about 10% divided into female babies. This current study, however, revealed stillbirth rates fourfold higher in male infants than in females for type 2 diabetes. However, the authors were cautious in total numbers and it would be useful to see similar data in other populations. The authors suggest that this could be explained by a combination of higher metabolic demand, known for male fetuses in the later stages of pregnancy, combined with vulnerability caused by male fetuses with smaller placenta, and therefore less compensatory reserve.

For both type 1 and type 2 diabetes, distribution of age, number of pregnancies, smoking percentage, and baseline scores were similar in mothers, regardless of whether the pregnancy ended at birth or at birth. Quickly, the authors note that there were also no significant differences in stillbirth rates when data were analyzed from a health board area or hospital delivery, indicating that variations in clinic-to-clinic care are not a risk factor on birthday.

In conclusion, this study, of over 5000 babies over the age of 18, considering a range of potential risk factors, clearly showed that maternal blood sugar and BMI are the major modifiable risk factors associated with birth in women with diabetes. Death rates are highest for babies born small because of their gestational age, but large babies are also at greater risk. "Achieving near-normal levels of sugar in the blood remains key to reducing risk," the authors suggest, recommending "methods to support women improve glucose in pregnancy, along with programs to optimize weight before pregnancy." Because death risk is very high, the authors recommend that "until a more accurate risk assessment during pregnancy becomes available, earlier may be considered an attractive option."