Diabetes, Fetal Demise, and Shoulder Dystocia: The Importance of Glucose Screening to Prevent Catastrophic Obstetric Outcomes

Abstract

Diabetes is associated with increased risk of stillbirth and shoulder dystocia. Compared with uncomplicated pregnancies, diabetic patients have a 4-6x risk of stillbirth and 2-3x risk of shoulder dystocia. A 34 yo G2P0010 presented with a 40+3 wga IUFD with nonstandard antenatal glucose screening. Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was not relieved by McRoberts, suprapubic pressure, Rubin II, Wood’s Screw, or posterior arm delivery. Nitroglycerine was administered, after which Wood’s Screw was successful resulting in delivery of an infant weighing 4190 grams (85th percentile for gestational age). A 31 yo G1 presented with a 37+1 wga IUFD. Her 28 wga three-hour GTT was notable for an elevated value at one hour (216 mg/dL). Admission labs included a hemoglobin A1c of 6.6. She had a vaginal delivery complicated by a 30-minute shoulder dystocia that was relieved via posterior axillary sling after failure of McRoberts, suprapubic pressure, Rubin II, Wood’s Screw, and Gaskin’s, resulting in the delivery of an infant weighing 3590 g (92nd percentile for gestational age). We present two cases of severe shoulder dystocia in patients who both presented with term IUFD and diabetic-range hemoglobin A1c. There is minimal literature on diabetic patients with pregnancies affected by both stillbirth and shoulder dystocia. These cases underscore the importance of glucose screening and control to prevent catastrophic obstetric outcomes.

Overview of techniques to manage shoulder dystocia during vaginal birth

“…Wide episiotomy is necessary to be performed to facilitate the procedures 7 , 19 , 41 - 43 . More specifically, the maneuver of Rubin–Wood needs more space in order to be efficient 7 , 12 , 19 , 35 , 37 , 39 , 42 .…”

“…This maneuver is inspired from the traditional procedures of dystocic deliveries in Guatemala. The mother is placed in a knee-hands position 7 , 27 , 35 , 37 or in a sprinter position 35 , 41 but never in a knee-chest position 7 , 35 . In this way the cavity of the sacrum increases and the gravity in combination with the traction of the posterior or anterior shoulder facilitates the release of the shoulder 27 , 35 .…”

“…Posterior axillary traction is recommended as a second internal maneuver if the delivery of the posterior shoulder fails 18 , 35 , 41 which, according to Ansell et al 17 , appears to have better results and is thus recommended to be used as the first internal maneuver if McRoberts’ with suprapubic pressure fails 37 . The health worker places a hand into the posterior aspect of the pelvis and with the thumb and first finger grasps the posterior shoulder around the axilla, and with the middle finger applies traction only through the axilla.…”

Comparison of factor XII levels in gestational diabetes, fetal macrosomia, and healthy pregnancies

“…The prevalence varies worldwide due to differences found in racial/ethnic groups, diagnostic criteria, and testing methods [ 3 ]. Adverse outcomes such as macrosomia, preeclampsia, and fetal/neonatal mortality can increase if GDM is not diagnosed and treated [ 4 ]. In GDM, elevated plasma coagulation activation markers are found (thrombin-antithrombin complex) and clotting factors (fibrinogen; factors VII, VIII, XI, and XII; kallikrein; and von Willebrand).…”