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Rudolph's Pediatrics, 22e

Chapter 48. Infant of a Diabetic Mother

Body Size
Insulin is the major anabolic hormone and glucose is the major anabolic fuel for fetal growth. In the setting of excess glucose and cellular uptake,
glycogen and fat synthesis increase, especially during the third trimester after 32 weeks. Macrosomia, which is defined as a birth weight above the 90th
percentile for gestational age, or greater than 4000 grams, is the result of excess fuel deposition, causing increased body fat, muscle mass, and
organomegaly, especially of the heart and liver. Skeletal growth is largely unaffected. Therefore, IDMs have higher weight than length and head
circumference percentiles. Macrosomia occurs in 15% to 45% of cases, which is 3 times higher than the general population.

The majority of the excess fat in IDMs is deposited centrally in the abdomen and intrascapular areas, placing the infant at risk for shoulder dystocia and
delivery by cesarean section. While linear relationships between insulin levels and birth weight have been shown,14 other metabolic fuels may
contribute to macrosomia in the IDM as well. Positive correlations have been demonstrated between maternal triglyceride levels, amino acids, and free
fatty acids with birth weight.15­17 Thus, macrosomia is likely multifactorial in nature.

The rate of delivery by cesarean section in diabetic women is 3 times higher than that of the general population, but the difference is not entirely
attributable to macrosomia. Given the concerns over shoulder dystocia and perinatal depression, caregivers are more prone to perform cesarean
deliveries because of the concerns for a poor outcome and the imperfect clinical ability to predict which infants are at the highest risk.18,19
Macrosomia can lead to a difficult vaginal delivery due to shoulder dystocia, with resultant birth injury or perinatal depression. Birth injuries, which
include cephalohematoma, subdural or ocular hemorrhage, facial palsy, brachial plexus injuries, clavicular fractures, and abdominal organ injury, are
2 to 4 times more common among IDMs, with macrosomic infants at the highest risk.

Not all IDMs are macrosomic. Mothers with advanced pregestational diabetes are at risk for giving birth to a small­for­gestational­age infant. Advanced
maternal vascular disease, seen in pregnant women with diabetes­associated retinal or renal vasculopathies and/or chronic hypertension, leading to
placental insufficiency, can result in fetal growth restriction and a deficiency of nutrients and oxygen.

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Body Size, Heather Morein French; Rebecca A. Simmons Page 1 / 1
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