Fetal death in pregnant diabetic women B-Khani Assistant professor of Isfahan University of Medical Science

Two major causes of perinatal mortality are unexplained fetal death and congenital malformations n In the past,sudden and unexplained still birth occurred in 10-30% of pregnancies complicated by IDDM.

Stillbirth has been observed after 36 week of pregnancy in patients with : Poor glycemic control Fetal macrosomia Hydramnios Vascular disease and pre-eclampsia

The precise cause of stillbirth remains unknown n Because extramedullary hematopoesis is frequently observed in stillborn IDMS choronic intrauterine hypoxia has been cited as a likely cause of these stillbirth n Blood sampling in these infants have shown acidemia accompanied by hypoxemia. n It has been postulated that fetal polycythemia and increased platelet aggregation thrombotic episodes could be underlying cause for late unexplained intra uterine death.

n Maternal diabetes may produce alterations in red blood cell oxygen release and placental flow. n Uterine blood flow IUGR was seen in diabetic vascolopathy

n Keto acidosis and pre-eclampsia two factors known to be associated with an increased risk of IUFD n In diabetic ketoacidosis,hypovolemia and hypotention caused by dehydration may reduce flow through the intervillous space n Whereas in pre-eclampsia narrowing and vasospasm of spiral arterioles may result

Result n Hyperinsulinemia in fetus of diabetic mother >metabolic rate oxygen requirements >metabolic rate oxygen requirements in the face of several factors such as : in the face of several factors such as : n Hyperglycemia n Ketoacidosis pre-eclampsia n Maternal vasculopathy Which can reduce placenta blood flow and fetal oxygenation

Malformation n Approximately 40% of perinatal deaths in IDDMs can be attributed to malformations n Major congenital anomalies is increased 2fold to 3 fold over that of general population. 2fold to 3 fold over that of general population.

The most frequent types of malformations involve: n The central nervous system n Cardiovascular n Gastrointestinal n Genitourinary n Skeletal system Cardiac malformations being the most common

The defect most often associated with diabetes occur organogenesis before 7 weeks gestation n Association between malformations and diabet control. It is important maintenance of near euglycemia beginning preconceputed and continuing throughout gestation n Altered fetal growth macrosomia IUGR IUGR Are associated with higher perinatal and neonatal mortality and morbidity

Fetal assessment n Measure the maternal serum alpha-feto protein level at 16weeks of gestation to screen for neural tube defects and other fetal anomalies perform an ultrasonographic examination at 16to 18 weeks of gestation.

n If indicated assess the fetal cardiac structure by echocardiography at 20 weeks of gestation. n During the third trimester,assessment of fetal growths and well-being becomes most important n fetal growths may be evaluated by serial ultrasonographic examination every 4-6weeks

Fetal well-being techniques: n Non stress test n Contraction stress test n Biophysical profile n Doppler velocimetry They are most often begun at 32 weeks once or twice a week until delivery

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