Adequacy of prenatal care and stillbirth

Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis

OBJECTIVE

Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022.

METHODS OF STUDY SELECTION

Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model.

TABULATION, INTEGRATION, AND RESULTS

From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2=82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2=82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2=0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2=0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2=87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2=0%).

CONCLUSION

Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42022303112.

Prenatal aneuploidy screening and its impact on stillbirth etiology evaluation

BACKGROUND

Stillbirth impacts 1% of all pregnancies in the USA with the underlying cause often remaining unknown. The objective of this study was to identify if prenatal aneuploidy screening impacted patient agreement to stillbirth evaluation.

METHODS

We performed a retrospective cohort study of patients with a singleton stillbirth after 20 weeks of gestation between October 2017 and December 2021. Demographics and stillbirth evaluation were collected for all patients. Multivariable logistic regression was performed adjusting for variables that were significant in univariate analysis.

RESULTS

A total of 81 persons experienced stillbirth during the study period. Approximately 59.3% of patients had prenatal aneuploidy screening: 39.5% integrated screening, 37.5% non-invasive prenatal testing (NIPT), and 22.9% quad screen. Prenatal genetic screening did not significantly impact patient agreement to placental pathology, serum laboratory evaluation, or fetal autopsy. Patients with NIPT were less likely to have genetic testing sent at the time of stillbirth compared to those with another aneuploidy screening (aOR 0.27, 95% CI 0.07-0.99).

CONCLUSIONS

Prenatal aneuploidy screening was not associated with patient acceptance of stillbirth evaluation. However, patients with NIPT were less likely to pursue further genetic testing during stillbirth evaluation, so further education regarding the benefit of karyotype and microarray should be included in patient counseling.

Rural Maternal Health Care Outcomes, Drivers, and Patient Perspectives

Rural communities are a vital segment of the US population; however, these communities are shrinking, and their population is aging. Rural women experience health disparities including increased risk of maternal morbidity and mortality. In this article, we will explore these trends and their determinants both within and external to the health care system. Health care providers, public health professionals, and policymakers should be aware of these social and structural factors that influence health outcomes and take action to reduce generational cycles of health disparity. Opportunities to improve the health and pregnancy outcomes for rural women and rural populations are highlighted.