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Diabetic Embryopathy:A most important human teratogen
Janice L.B. Byrne, M.D., FACMG,FACOGUniversity of Utah
Maternal-Fetal Medicine / Clinical GeneticsThe Utah Fetal Center at Primary Children’s Hospital
Dr. Byrne has no conflict of interest related to the content of this presentation.
Potential benefits of prenatal diagnosis
Search for other structural abnormalities that may impact on diagnosis, survival, prognosis
Determination of fetal karyotype, other testing
Genetic counseling Discussion of reproductive options
(termination vs. continuation of pregnancy)
Diabetes and pregnancy
Definitions Pregestational diabetes (type I or II):
○ Diabetes predates pregnancy Gestational diabetes (GDM):
○ Any degree of glucose intolerance initially diagnosed during pregnancy
○ Diagnosis by oral glucose tolerance test from 24-28 weeks gestation
Diabetes and pregnancy
By definition, GDM resolves following pregnancy Recurrence in subsequent pregnancies is
common Increased risk of developing type II diabetes (40-
50% within 10 years) Controversy exists regarding risk of
anomalies in GDM Anomalies in GDM may reflect an undiagnosed
type II diabetic
Epidemiology of Diabetes in Pregnancy
Pregestational 25.3 per 1,000 pregnant women 13% of all diabetes in pregnancy Prevalence increasing in USA, in parallel with
increasing obesity rate Rate varies with ethnic group and age
Epidemiology of Diabetes in Pregnancy
Gestational Estimated to affect 1-14% of pregnancies in US,
depending upon population studied and diagnostic test used
Risk factors○ Older age○ Multiple gestation○ Previous GDM ○ Previous macrosomic infant
Malformations and diabetes
Major malformations in 6-10% of infants born to diabetic mothers 2-4x higher rate than in nondiabetics Poor metabolic control, especially in 1st trimester,
increases risk of malformations Structural anomalies, especially cardiac, account
for 50% of perinatal deaths According to the data from Utah Birth Defects
Network, maternal diabetes is the most common teratogen in our birth cohort
Malformations and diabetes
Glycosylated hemoglobin (HbA₁C) provides retrospective index of glycemic status over preceding 8-12 weeks
Correlates with risk of malformations < 6.9% → minimal increased risk over baseline 7-8.5% → 5% anomalies > 10% → 22% anomalies
Malformations and diabetes
Even with excellent diabetic control, risk of malformations greater than that of a non-diabetic
Overt diabetic first recognized during pregnancy has similar risk for embryopathy as a known pregestational diabetic
Cystic fibrosis-related diabetes (CFRD) Uncertain malformation risk due to rarity of
pregnancy in this condition
Etiology of diabetic embryopathy
Metabolic derangements associated with hyperglycemia may contribute to teratogenesis Exact mechanism uncertain but likely multifactorial
Many theories center on role of hyperglycemia in increasing oxidative stress
Etiology of diabetic embryopathy
Hyperglycemia triggers apoptotic signaling pathways Inhibition of cell survival pathways leads to
embryonic malformations Caspases (cysteine proteases active in the
cascade of apoptosis) currently under investigation for their role in pathogenesis of diabetic embryopathy
Inhibitors of caspase activation may have protective effect against high glucose induced NTDs
Imaging in diabetic embryopathy
Best diagnostic clue Abnormal growth + structural anomalies in fetus of
diabetic mother○ May be macrosomic (> 90th%tile), large for
gestational age (LGA), or growth restricted (IUGR)○ Most common anomalies include: Cardiac Central nervous system Renal Skeletal
Imaging in diabetes
GDM- fetus often macrosomic Accelerated growth apparent by late 2nd trimester
○ Disproportionate increase in abdominal and head circumferences
○ Increased skin, subcutaneous tissue (trunk, head)
○ Polyhydramnios common IUGR more common in pregestational
diabetes, although macrosomia can also occur
Macrosomia in diabetes
Gestational diabetes5200g at 32 wk. gestation
Pregestational diabetes6670g at term
Imaging in diabetic embryopathy
Caudal dysplasia/ regression sequence Malformation complex characterized by
varying degrees of developmental failure involving legs, lumbar, sacral and coccygeal vertebrae and corresponding segments of the spinal cord
Lower extremity malposition (“tailor’s posture” or “Buddha pose”)
16% of cases due to maternal diabetes
Imaging in diabetic embryopathy
Caudal dysplasia/ regression
Imaging in diabetic embryopathy
Central nervous system (CNS) anomalies: 3-20x increase over non-diabetic Anencephaly Spina bifida Holoprosencephaly
Imaging in diabetic embryopathy
VentriculomegalyHoloprosencephaly
Myelomeningocele
Imaging in diabetic embryopathy
Cardiac anomalies: 5x increase over non-diabetic Transposition of great arteries Heterotaxy Cardiomyopathy (may be transient)
○ May be seen in poorly controlled gestational diabetic
Imaging in diabetic embryopathy
Cardiomyopathy with thick interventricular septum
Imaging in diabetic embryopathy
Extremities Preaxial polydactyly of feet and hands- very
specific for diabetic embryopathy Syndactyly- may be complex Femoral hypoplasia Angulated bones, especially of legs
Imaging in diabetic embryopathy
Femoral hypoplasia/Complex tib-fib
Preaxial polydactyly
Imaging in diabetic embryopathy
Genitourinary (GU) Renal agenesis Multicystic dysplastic kidneys
Gastrointestinal (GI) Anorectal malformation/ atresia
Non-specific Single umbilical artery Polyhydramnios Oligohydramnios Microtia
Imaging in diabetic embryopathy
Potter’s faciesBilateral renal agenesis
Multicystic dysplastickidneys
Unilateral renal agenesis
Anal Atresia
Microtia
Imaging in diabetic embryopathy
Imaging challenges in diabetes Maternal obesity! Maternal obesity! Maternal obesity! Too much amniotic fluid Too little amniotic fluid Late diagnoses
Multidisciplinary team approach to management
Optimize timing/ mode/ location of delivery Provide appropriate care to families and their
children with congenital malformations Coordination of care with primary provider, other
specialties, other services (SW, hospice etc.) Availability of fetal treatment when indicated Recurrence risk assessment with
recommendations for future pregnancy management
Questions?