Intrauteriner Tod des Feten bei präkonzeptionellem Diabetes, Gestationsdiabetes und Schwangerschaften ohne diabetische Stoffwechsellage. Ergebnisse der Perinatalstatistik Niedersachsen

Zusammenfassung

Fragestellung: Die Prävalenz des intrauterinen Fruchttodes (IUFT) sowie die diesbezüglichen Risikofaktoren für präkonzeptionelle Diabetikerinnen, Gestationsdiabetikerinnen und Schwangerschaften ohne diagnostizierten Diabetes wurden vergleichend untersucht. Methode: Die Daten der Perinatalerhebung Niedersachsen für die Jahre 1987 bis 1999 wurden retrospektiv für Schwangere mit präkonzeptionellem Diabetes mellitus (PDM: n = 3351), Gestationsdiabetes (GDM: n = 3954) und Schwangerschaften ohne Diabetes (KDM: n = 887 779) analysiert. Ergebnisse: Intrauteriner Fruchttod: PDM n = 46 (1,35 %), GDM n = 32 (0,79 %), KDM n = 2756 (0,31 %); Odds Ratio (OR) und 95 %-Konfidenzintervall für PDM vs. KDM 4,468 (3,332 - 5,992; p<0,01), OR für GDM vs. KDM 2,595 (1,829 - 3,682; p<0,01). Zeitpunkt des Todes vor der 32. SSW: PDM 13,0 %, GDM 12,5 %, KDM 27,7 %, (p<0,05 für PDM vs. KDM); Zeitpunkt des Todes zwischen der 32. und 36. SSW: PDM 37,0 %, GDM 43,75 %, KDM 33,0 %; Zeitpunkt des Todes > 36. SSW: PDM 50,0 %, GDM 43,75 %, KDM 39,3 % (p<0,05 für PDM vs. KDM). Anteil der verstorbenen Kinder < 10. Gewichtsperzentile: PDM 15,2 %, GDM 6,3 %, KDM 28,7 %; Anteil verstorbener Kinder > 90. Gewichtsperzentile: PDM 41,3 %; GDM 37,5 %; KDM 8,7 % (p<0,01 jeweils für PDM bzw. GDM vs. KDM). Schlussfolgerung: Das Risiko des intrauterinen Fruchttodes ist in diabetischen Schwangerschaften weiterhin erhöht. Dieses gilt insbesondere für hypertrophe Kinder, während in nichtdiabetischen Schwangerschaften die hypotrophen Kinder gefährdeter sind.

Abstract

Object: The prevalence of intrauterine fetal death as well as the relevant risk factors in pregnancies of women with preconceptional and gestational diabetes mellitus and non-diabetic women were investigated. Methods: The data of the Perinatal Registry of Lower Saxony between 1987 and 1999 for pregnancies of women with preconceptional diabetes mellitus (PDM, n = 3351), gestational diabetes mellitus (GDM, n = 3954) and women without diabetes mellitus (non-diabetic pregnancies, NDM, n = 887,779) were retrospectively analysed. Results: Intrauterine fetal death occurred in 46 women with PDM (1.35 %), 32 women with GDM (0.79 %) and 2756 non-diabetic women (0.31 %). The odds ratio (OR, 95 % CI) for PDM vs. NDM was 4.468 (3.332 - 5.992; p < 0.01) and for GDM vs. NDM it was 2.595 (1.829 - 3.682; p < 0.01). The percentage of death, which occurs before the 32^nd week of gestation, was 13 % in pregnancies with PDM, 12.5 % in pregnancies with GDM and 27.7 % in non-diabetic pregnancies. 50 % of fetal deaths in the PDM group, 43.8 % of those in the GDM group and 39.3 % of those in the NDM group occurred after the 36^th week of gestation. The percentages of dead fetuses who were under the 10^th percentile of growth (small for gestational age, SGA), in pregnancies with PDM, GDM and NDM were 15.2 %, 6.3 %, and 28.7 %, respectively. The percentages of dead fetuses above the 90^th percentile of growth (large for gestational age, LGA) were 41.3 % (PDM), 37.5 % (GDM), and 8.7 % (NDM), (p < 0.01 for PDM vs. NDM and for GDM vs. NDM). Conclusion: The risk of intrauterine fetal death in pregnancies of diabetic women is still increased. It seems that especially the LGA fetuses of diabetic mothers and SGA fetuses of non-diabetic mothers are at greater risk of intrauterine death.

Totgeburt - Diabetes und Schwangerschaft - Risikoschwangerschaft

Stillbirth - diabetes and pregnancy - high risk pregnancy

Literatur

• 1 Ahlenius I, Floberg J, Thomassen P. Sixty-six cases of intrauterine fetal death. A prospective study with an extensive test protocol.  Acta Obstet Gynecol Scand. 1995;  74(2) 109-117
• 2 Frøen J F, Arnestad M, Frey K, Vege Å, Saugstad O D, Stray-Pedersen B. Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986 - 1995.  Am J Obstet Gynecol. 2001;  184 (4) 694-702
• 3 Frøen J F, Gardosi J O, Thurmann A, Francis A, Stray-Pedersen B. Restricted fetal growth in sudden intrauterine unexplained Death.  Acta Obstet Gynecol Scand. 2004;  83(9) 801-807
• 4 Gardosi J, Mul T, Mongelli M, Fagan D. Analysis of birth-weight and gestational age in antepartum stillbirths.  Br J Obstet Gynaecol. 1998;  105 524-530
• 5 Künzel W. Intrauterine fetal death during pregnancy: limitations of fetal surveillance.  J Obstet Gynaecol Res. 1998;  24(6) 453-460
• 6 Petersson K, Bremme K, Bottinga R, Hofsjo A, Hulthen-Varli I, Kublickas M, Norman M, Papadogiannakis N, Wanggren K, Wolff K. Diagnostic evaluation of intrauterine fetal deaths in Stockholm 1998 - 1999.  Acta Obstet Gynecol Scand. 2002;  81(4) 284-292
• 7 Fretts R C. Etiology and prevention of stillbirth.  Am J Obstet Gynecol. 2005;  193 1923-1935
• 8 Many A, Elad R, Yaron Y, Eldor A, Lessing J B, Kupfermine M J. Third-trimester unexplained intrauterine fetal death is associated with inherited thrombophilia.  Obstet Gynecol. 2002;  99(5 PT 1) 684-687
• 9 Horn L C, Langner A, Stiehl P, Wittekind C, Faber R. Identification of the causes of intrauterine death during 310 consecutive autopsies.  Eur J Obstet Gynecol Reprod Biol. 2004;  113(2) 134-138
• 10 Ogunyemi D, Jackson U, Buyske S, Risk A. Clinical and pathologic correlates of stillbirths in a single institution.  Acta Obstet Gynecol Scand. 1998;  77(7) 722-728
• 11 Ahlenius I, Thomassen P. The changing panorama of late fetal death in Sweden between 1984 und 1991.  Acta Obstet Gynecol Scand. 1999;  78 408-414
• 12 Morrison I, Oslen J. Weight-specific stillbirths and associated causes of death. An analysis of 765 stillbirths.  Am J Obstet Gynecol. 1985;  152 975-980
• 13 Bayerische Landesärztekammer und kassenärztliche Vereinigung Bayerns: BPE Jahresberichte 1983, 1993 und 1994. 
• 14 Eurostat: Bevölkerungsstatistik 1994. EGKS-EG-EAG Brüssel; 1994
• 15 Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der stationären Versorgung BAQ: Geburtshilfe. Jahresauswertung 2005, Modul 16/1. 
• 16 Martin J A, Hamilton B E, Sutton P D, Ventura S J, Menacker F, Munson M L. Birth: final data for 2002.  Natl Vital Stat Rep. 2003;  52 1-113
• 17 Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher N J. Pre-pregnancy weight and the risk of stillbirth and neonatal death.  Br J Obstet Gynaecol. 2001;  112(4) 403-408
• 18 North A F, Mazumdar S, Logrillo V M. Birth weight, gestational age, and perinatal deaths in 471 infants of diabetic mothers.  J Pediatr. 1977;  90 444-447
• 19 Rasmussen M J, Firth R, Foley M, Stronge J M. The timing of delivery in diabetic pregnancy: a 10-year review.  Aust N Z J Obstet Gynaecol. 1992;  32 313-317
• 20 Langer O, Rodriguez D A, Xenakis E MJ, McFarland M B, Berkus M D, Arredondo F. Intensified versus conventional management of gestational diabetes.  Am J Obstet Gynecol. 1994;  170 1036-1047
• 21 Fraser R. Diabetic control in pregnancy and intrauterine growth of the fetus.  Br J Obstet Gynaecol. 1995;  102 275-277
• 22 von Kries R, Kimmerle R, Schmidt J E, Hachmeister A, Böhm O, Wolf H G. Pregnancy outcome in mothers with pregestational diabetes: a population-based study in North Rhine (Germany) from 1988 to 1993.  Eur J Pediatr. 1997;  156 963-967
• 23 Salvesen D R, Brudenell J M, Proudler A J, Crook D, Nicolaides K H. Fetal pancreatic ß-cell function in pregnancies complicated by maternal diabetes mellitus: relationship to fetal acidemia and macrosomia.  Am J Obstet Gynecol. 1993;  168 1363-1369
• 24 Carson B S, Philipps A AF, Simmons M A, Battaglia F C, Meschia G. Effects of a sustained insulin infusion upon glucose uptake and oxygenation of the ovine fetus.  Pediatric Res. 1980;  14 147-152
• 25 Widness J A, Susa J B, Garcia J F, Singer D B, Sehgal P, Oh W, Schwartz R, Schwartz H C. Increased erythropoiesis and elevated erythropoietin in infants born to diabetic mothers and in hyperinsulinemic Rhesus fetuses.  J Clin Invest. 1981;  67 637-642
• 26 Widness J A, Teramo K A, Clemons G K, Voutlainen P, Steuman U H, McKinlay S M, Schwartz R. Direct relationship of antepartum glucose control and fetal erythropoietin in human type I (insulin-dependent) diabetic pregnancy.  Diabetologia. 1990;  33 378-383
• 27 Salvesen D R, Brudenell J M, Nicolaides K H. Fetal polycythemia and thrombocytopenia in pregnancies complicated by maternal diabetes mellitus.  Am J Obstet Gynnecol. 1992;  166 1287-1292
• 28 Leitlinien der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Die ärztliche Betreuung der schwangeren Diabetikerin. Frauenarzt 1999 40: 1475
• 29 Sims M A, Collins K A. Fetal death. A 10-year retrospective study.  Am J Forensic Med Pathol. 2001;  22(3) 261-265
• 30 Huang D, Usher R, Kramer M, Yantet H, Morin L, Fetts R. Determinants of unexplained antepartum fetal deaths.  Obstet Gynecol. 2000;  95 215-221
• 31 Beischer N A, De Garis C N. Unexplained intrauterine death near term.  Austr N Z J Obstet Gynaecol. 1986;  26 99-101
• 32 Ong S, Danielian P. Unexplained stillbirths: are they preventable?.  Int J Gynaecol Obstet. 2000;  69 159-161
• 33 Weiss P AM. Diabetes und Schwangerschaft. Springer Wien New York; 2002: 351
• 34 Weiss P AM. Klinische Bedeutung des Geburtsgewichtes bei Diabetes mellitus.  Gynäkologe. 1998;  31 58-67
• 35 Weiss P AM. Gestational diabetes: a survey and the Graz approach to diagnosis and therapy. In: Weiss PAM, Coustan DR (eds) Gestational Diabetes. Wien New York; Springer 1988: 1-55
• 36 Jovanovic L, Peterson C M. Optimal insulin delivery for the pregnant diabetic patient.  Diabetes Care. 1982;  5 Suppl. 1 24-37
• 37 Roversi G D. Intensive treatment of diabetes during pregnancy.  Diabetes Care. 1985;  8 522-523
• 38 Hanson U, Persson B. Outcome of pregnancies complicated by type 1 insulindependent diabetes in Sweden: acute pregnancy complications, neonatal mortality and morbidity.  Am J Perinatol. 1993;  10 330-333
• 39 White P. Classification of obstetric diabetes.  Am J Obstet Gynecol. 1978;  130 228-230
• 40 Cnattingius S, Berne C, Nordstrom M L. Pregnancy outcome and infant mortality in diabetic patients in Sweden.  Diabet Med. 1994;  11 696-700