he incidence of macrosomia rises signiicantly when mean maternal blood glucose concentrations chronically exceed 130 mg/dL (Hay, 2012). Hammoud and coworkers (2013)
TABLE 57-5. Pregnancy Outcomes of Births in Nova TABLE 57-6. Major Congenital Anomalies in 36,345 Scotia from 1988 to 2002 in Women with Neonates Born to Women with Diabetes and without Pregestational Diabetes between 2004 and 201e1 (n.=.S16) (n.=.lS0,.S98) Factor P value �pe1.DM Type.2DM GDM Organ System n = 482 n = 4166 n = 31,700
Gestational 28 9 <.001 Cardiac 38 272 1129
Preterm birth 28 5 <.001 Urinary 3 28 260 <.001 CNS 13 64
FIGURE 57-3 This 6050-g macrosomic infant was born to a woman with gestational diabetes.
15.8 400.) 11.7 30 25 5 3/1e9 5 2/1e7 0 <6 6-6.9 7-7.9 �8 FIGURE 57-2 The frequency of major congenital malformations in newborns ofwomen with pregestational diabetes stratified by hemoglobin Ale levels at first prenatal visit. (Data from Galindo A, Burguillo AG, Azriel S, et al: Outcome offetuses in women with pregestational diabetes mellitus, J Perinat Med. 2006;34(4):323-331.) reported that the macrosomia rates for Nordic women with type 1, type 2, or gestational diabetes were 35 percent, 28 percent, and 24 percent, respectively. As shown in 57-4, the birthweight distribution of neonates of diabetic mothers is skewed toward consistently heavier birthweights. In the study by Hammoud and colleagues (2013), fetal growth profiles from 897 sonographic examinations in 244 women with diabetes were compared with 843 examinations in 145 control women. he abdominal circumference grew disproportionately larger in the diabetic groups. Analysis of head circumference/abdominal circumference (HC/AC) ratios shows that this disproportionate growth occurs mainly ..0
FIGURE 57-4 Distribution of birthweight standard deviations from the normal mean for gestational age in 280 newborns of diabetic mothers and in 3959 neonates of nondiabetic mothers. (Reproduced with permission from Bradley RJ, Nicolaides KH, Brudenell JM.: Are all infants ofdiabetic mothers "macrosomic"7 BMJ 1988 Dec 17;297(6663):1o583-1o584') in diabetic pregnancies that ultimately yield macrosomic newborns. hese findings comport with the observation that virtually all neonates of diabetic mothers are growth promoted, and accelerated fetal growth is particularly evident in women with poor glycemic control.
Unexplained Fetal Demise. Worldwide, the risk offetal death is three to four times higher in women with pregestational diabetes (Cardosi, 2013; Patel, 2015). Stillbirth without an identiiable cause is a phenomenon relatively limited to pregnancies complicated by overt diabetes. These stillbirths are "unexplained" because common factors such as obvious placental insuiciency, placental abruption, fetal-growth restriction, or oligohydramnios are not identified. hese fetuses are typically large for gestational age and die before labor, usually late in the third trimester.