Fetal death in diabetic pregnancy: An anticipated complication? A systematic review of predictability, residual risk, and preventability in the modern era
Sarma Nursani Lumbanraja, Dudy Aldiansyah, Muara Panusunan Lubis, Melvin Nova Gunawanto Barus, Wiku Andonotopo, Muhammad Adrianes Bachnas, Wisnu Prabowo, Eric Edwin Yuliantara, Mochammad Besari Adi Pramono, Julian Dewantiningrum, Efendi Lukas, I Nyoman Hariyasa Sanjaya, Anak Agung Gede Putra Wiradnyana, Anak Agung Ngurah Jaya Kusuma, Khanisyah Erza Gumilar, Ernawati Darmawan, Muhammad Ilham Aldika Akbar, Dovy Djanas, Aloysius Suryawan, Ridwan Abdullah Putra, Anita Deborah Anwar, Cut Meurah Yeni, Nuswil Bernolian, Waskita Ekamaheswara Kasumba Andanaputra, Milan StanojevicFetal death in pregnancies complicated by diabetes has long been framed as a preventable outcome of inadequate metabolic control. Yet, despite continuous glucose monitoring, refined insulin strategies, and standardized surveillance pathways, stillbirth persists at rates that remain clinically and ethically unsettling. This systematic review was undertaken to examine whether fetal death in diabetic pregnancy is truly an anticipated complication, and if so, to clarify what can be predicted, what remains irreducible, and where current prevention paradigms fall short. We conducted a Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 – compliant systematic review of observational studies, randomized evidence, registry analyses, meta-analyses, and mechanistic investigations addressing fetal death or stillbirth in gestational and pregestational diabetes. Thirty-nine studies met the inclusion criteria following structured screening and eligibility assessment. Data were synthesized across epidemiologic, metabolic, placental, fetal, and care-system domains, with qualitative appraisal of risk of bias and evidentiary coherence. Across contemporary cohorts, diabetes was consistently associated with excess fetal death risk, even under guideline-concordant care. Predictive signals emerged not from single metrics, but from converging patterns: glycemic variability rather than mean control, late-gestation insulin requirement shifts, placental structural and vascular pathology, and subtle fetal growth or cardiac adaptations. Importantly, several pathways leading to fetal demise were biologically advanced before clinical detection, exposing a zone of residual risk that current surveillance cannot reliably intercept. These findings suggest that fetal death in diabetic pregnancy is neither fully random nor fully preventable. Rather, it reflects dynamic interactions between maternal metabolism, placental biology, fetal adaptation, and health-system response. Future progress will require a shift toward anticipatory, placenta-centered, and system-integrated models of care, alongside honest recognition of the biological limits of prevention in modern perinatology.