14-09-2013

Infant ofDiabetic Mother

Dr Ufaque Batool Korai

House Officer at pediatrics Unit I I

“Headings….”IntroductionDefinitionIncidence PathophysiologyRisk FactorsFetal effects of maternal hyperglycemiaPerinatal complications of diabetes in pregnancyClinical manifestationsNeonatal complications of diabetes in pregnancyInvestgations Neonatal management and Treatment Prognosis Prevention

“Introduction”•Approximately 6% of pregnancies are complicated by maternal diabetes mellitus (80% of which are gestational).

•Maternal hyperglycaemia can result in fetal hyperglycaemia and then secondary fetal hyperinsulinism.

•Insulin is the main 'growth hormone' of the fetus and therefore infants of diabetic mothers (IDM) are often macrosomic (> 4,000 g) or large for gestational age (>90th percentile).

•The problems associated with being IDM relate to the effects of hyperinsulinism and/or macrosomia

•The macrosomia is due to excessive fat deposition, visceral organ hypertrophy (except brain and kidney) and acceleration of body mass accretion.

•Macrosomic IDMs have higher rates of neonatal morbidity and mortality.

“Definition”

An infant of a diabetic mother is a baby born to a mother who has diabetes. The phrase specifically refers to a baby who is born to a mother who had persistently high blood sugar (glucose) levels during pregnancy .

“Incidence”

•Insulin dependent diabetes occurs in 0.5% of all pregnancies.

•In addition 1-3% of women shows biochemical abnormalities during pregnancy consistent with gestational diabetes.

“Pathophysiology” abnormal fetal developmental physiology

increased flux of glucose from mother to fetus

Hyperglycemia, Hyperinsulinemia, Increased metabolic rate, hypoxemia

Redistribution of cardiac output, Increased release of norepinephrine, and blunted release of glucagon.

•More fat is stored in adipocytes

•More glycogen is stored in the liver

•The heart may develop asymmetric septal hypertrophy.

•lung metabolism is altered to delay the appearance of mature surfactant.

•At birth, the macrosomic IDM develops hypoglycemia that has a multifactorial basis (hyperinsulinemia, hypoglucagonemia, and probably diminished gluconeogenic and cortisol production rates).

• The IDM may experience respiratory symptoms from one of three causes: IRDS, persistent pulmonary hypertension, or congestive heart failure.

•Hyperbilirubinemia may occur because of increased rate of hemolysis; hypocalcemia and hypomagnesemia are likely within the first 3 days in association with a sluggish PTH response; and abnormal levels of inhibitors of fibrinolysis and platelet prostaglandin E-like substances may stimulate abnormal thrombosis.

“Risk Factors”Fetal macrosomia posses health risk for mother and baby both during pregnancy and after child birth.

•Maternal diabetes•A history of fetal macrosomia•Maternal obesity•Excessive weight gain during pregnancy•Previous pregnancies•Gender of baby•Overdue pregnancy•Maternal age

“Fetal effects of maternal hyperglycemia”

•Poor glycaemic control during embryogenesis can result in a 4 to 8 fold increase in congenital malformations, including

cardiac defectsCNS defects (including anencephaly and spina bifida)genitourinary and limb defects

•Macrosomia leading to increased risk ofshoulder dystociaclavicular fracturebrachial plexus injuryfacial nerve injurycephalhaematomaasphyxiaperinatal and neonatal mortality

Continues….•Episodic fetal hypoxia stimulated by episodic maternal hyperglycaemia leads to an outpouring of adrenal catecholamines, which can cause

HypertensionCardiac hypertrophyStimulation of erythropoietin, leading to polycythaemia and therefore hyperviscosityIncrease risk of thrombosisHyperbilirubinaemia (increased red cell mass)

“Perinatal complications of diabetes in pregnancy”

• Increased perinatal mortality due too congenital malformationso extreme prematurityo fetal demiseo growth restrictiono intrapartum asphyxiao RDS

• Birth injuryo Shoulder dystociao Brachial plexus trauma

“Clinical Manifestation”

Large

Large and plump baby (macrosomia) with puffy facies.

Infant may also be of normal or low birth weight, particularly if they are delivered before term or association with maternal disease.

Infant may be jumpy, tremulous & hyperexcitable during the 1st 3 days of life although hypotonia, lethargy and poor sucking also may occur.

Hypoglycemia

Hypocalcemia

Sign of respiratory distress secondary to immature lungs can be noted on examination.

Cardiac disease may be present.

Gross congenital anomalies may be noted on physical

examination

“Neonatal complications of diabetes in pregnancy”

MacrosomiaSmall for gestational age Polycythaemia and hyperviscosityHypoglycaemia incidence varies from 25-40% usually presents within 1-2 hours after delivery.Hypocalcaemia is (up to 50%) serum Ca levels are lowest at 24-72 hours of age.HypomagnesaemiaBirth asphyxia 25%Birth trauma

“Neonatal complications continues…”

Hyperbilirubineamia Respiratory distress syndrome 3%Hypertrophic and congestive Cardiomyopathy 50%Renal venous thrombosisChildhood obesityMetabolic syndromeCongenital malformation (6.4%) Cardiac Defects Renal Defects GIT Defects Neurologic Defects Skelatal Defects.

“According to resent research conducted at peshawr in july 2012”

42 consecutive cases of infants of Diabetic mothers were enrolled in the study, all their maternal Hx esp obst Hx n complete neonatal examination was done….

The Results of that study were

Out of 42 diabetic mothers, gestation diabetes was seen in 71.4%while pre-conceptional diabetes was seen in 28.5%. The male Infants of Diabetic Mothers in this study were 69%. Infant of Diabetic Mothers delivered by C-section were 45%.Macrosomia 40.4% was found to be the most common complication followed b hypoglycaemia 23.8%.

The mortality rate in that study was 4.7%

“Investigations” Serum glucose levels should be checked at delivery and at ½ , 1, 1 ½ . 2, 4, 8, 12, 24, 36 and 48 hours of age.

Serum calcium levels

The hematocrit should be checked at birth and at 4 n 24 hours of age.

Serum bilirubin levels should be checked as indicated by physical examination.

ABGs, CBC, cultures are gram stains should be obtained as clinically indicated.

Radiological studies are not necessary unless there is evidence of cardiac, respiratory or skeletal problems

ECG and echocardiography should be performed if hypertrophic cardiomyopathy or a cardiac malformation is suspected

“Neonatal management and treatment”

Upon delivery, the infant should be evaluated in the usual manner.Blood glucose levels and the hematocrit should be obtained.Observe for jitteriness, tremors, convulsions, apnea, weak cry and poor sucking.A physical examination should be performed paying special attention to heart, kidneys, lungs n extremities.

For hypoglycaemia Infuse a bolus of 2 ml/kg of 10% glucose solution at a rate of 1.0ml/min, then give a continuous infusion of 10% glucose at a rate of 6-8 ml/kg/min and increase the rate as needed to maintain a normal blood glucose (. 40-50mg/dl).

The level should be followed every 30-60 mints until stable.

The highest concentration of glucose that can be infused through a peripheral line is 12.5%.

Management continues…..

Other complications e.g hypocalcemia, RDS, Birth Asphyzia cardiomyopathy, hyper bilirubinemia etc should be managed accordingly.

Start feeding when baby is stable and is able to suck, and has no apparent complications.

Encourage breast feeding.

“Prognosis”

The morbidity and mortality is decreased with adequate control of diabetes during the diabetic pregnancy

The risk of subsequent diabetes in the infants of these women is atleast 10 times greater than in the normal population.

Physical development is normal, but oversized infants may be presispoed to obesity in childhood that may extend into adult life.

“Prevention”To prevent complications, the mother needs care throughout her pregnancy. Controlling blood sugar and getting diagnosed with gestational diabetes early can prevent many of the problems that can occur with this condition.

Lung maturity testing may help prevent breathing complications due to immature lungs if the baby is being delivered more than a week before the due date.

Carefully monitoring the infant in the first hours after birth may prevent complications due to low blood sugar. Monitoring and treatment in the first few days may prevent complications due to high bilirubin levels.

“it might be difficult to prevent MACROSOMIA, but we can

promote a healthy pregnancy”

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