Al Wattar, Bassel H. (2019) Stillbirth and gestational diabetes : two linked health issues in need of a global response. BJOG: An International Journal of Obstetrics & Gynaecology . doi:10.1111/1471-0528.15682

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Abstract

Interventions to reduce the rates of stillbirths in high‐income countries have had little success to date (Lancet 2016;387:691–702). Still, effective antenatal screening and mitigation of risk factors for stillbirth offer hope to identify at‐risk populations and deliver targeted interventions improving pregnancy outcomes.

The paper by Stacey et al. (BJOG 2019; https://doi.org/10.1111/1471-0528.15659) offers an important insight into the role of effective screening for gestational diabetes (GDM) in reducing the associated risks for stillbirth in affected and at‐risk women. Receiving specialist multidisciplinary care reduced the established risk for stillbirth to similar levels in a low‐risk population. The association between fasting plasma glucose levels and the risk for stillbirth was linear, emphasising the importance of early detection and treatment.

However, consensus is lacking among international health regulators on the appropriate thresholds for the diagnosis of GDM and the detection of ‘overt diabetes’ (McIntyre et al. Diabetes Care 2016;39:53–4). The current diagnostic criteria for GDM supported by the IADPSG and the WHO carries a significant economic burden and could impact healthcare provision, potentially leading to suboptimal outcomes. Similarly, more relaxed criteria might fail to deliver the needed impact to reduce stillbirth (Hanna et al. Clin Med 2017;17:108–13). Careful evaluation of locally available resources and healthcare delivery systems, guided by involved stakeholders, is warranted to conform to the international drive to optimise perinatal health.

Other important questions remain, such as the timing of screening in pregnancy, the value of universal screening, and the association with other predisposing risk factors (International Association of Diabetes and Pregnancy Study Groups Consensus Panel. Diabetes Care 2010;33:676–82).

Interventions to address the association between GDM and stillbirth should be considered as a continuum, from pre‐conception to postpartum care in planning for future pregnancy (Ratner et al. J Clin Endocrinol Metab 2008;93:4774–9). Stillbirth prevention should not be addressed as a stand‐alone issue and requires an integrated programmatic approach. With many interventions currently being evaluated in randomised trials, accurate reporting on stillbirth and other key offspring outcomes is essential to attenuate this persistent epidemic. An ultimate strategy of individualised prediction and targeted intervention to mitigate reversible risk factors requires significant institutional engagement from major health funders.

Both GDM and stillbirth are truly global health challenges with a significant impact on the wellbeing of society. Coordinated wide‐scale interventions driven by quality evidence synthesis are urgently needed to address these important health issues.

Item Type:	Journal Item
Divisions:	Faculty of Medicine > Warwick Medical School > Biomedical Sciences > Cell & Developmental Biology Faculty of Medicine > Warwick Medical School > Biomedical Sciences Faculty of Medicine > Warwick Medical School
Journal or Publication Title:	BJOG: An International Journal of Obstetrics & Gynaecology
Publisher:	Wiley-Blackwell Publishing, Inc
ISSN:	1470-0328
Official Date:	8 April 2019
Dates:	Date Event 8 April 2019 Published 31 March 2019 Accepted
DOI:	10.1111/1471-0528.15682
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access
Open Access Version:	Publisher

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