Infant of diabetic

mother

Dr: eman khammas

al-sadi

)


(

6 :
He is Who shapes you in the
wombs as He pleases.
There is no god but He,
the Exalted in Might, the
Wise

Objectives

Introduction
Pathophysiology
Epidemiology
Complications
Management
Prognosis

Introduction
1. Diabetes is the most common medical
complication of pregnancy.
2. Fetal and neonatal mortality rates were as
high as 65%.
3. nowadays nearly 30-fold decrease in
morbidity and mortality rates.
4. there is still an increased risk of
complications.

Definitions
Gestational diabetes mellitus (GDM):
any abnormal glucose intolerance that begins or is
first recognized during pregnancy using glucose
tolerance test.

Pathophysiology

 estrogen and progesterone

beta-cell hyperplasia
insulin (hyper insulinism)
human placental lactogen
lipolysis in the mother
glycerol and fatty acids
preserving the glucose and aminoacid for the fetus
Glucose and amino acids traverse the placental membrane
Before 20 weeks' gestation, fetal islet
cells are incapable of responding,
subjecting the fetus to unchecked
hyperglycemia (IUGR)
before 9 week (malformation)*

After 20 weeks' gestation, the fetus

responds to hyperglycemia with
pancreatic beta-cell hyperplasia and
insulin levels (macrosomia).(TTN)
(birth injury ) (cardiomegaly)

fetal basal metabolic rate and oxygen consumption

erythropoieten production polycythemia. (thrombocytopnia) (stroke)
redistributes iron organs iron deficient ( heart and Neurodevelop)
insulin levels inhibit the maturational effect of cortisol on the lung (RDS)

Mortality
Major congenital malformations are
found in 5-9% of affected infants.
the stillbirth and perinatal mortality
rate is 5 times the rate in the general
population.
neonatal mortality rates 15 times
infant mortality rates are 3 times .

Complications

Complication

Fetal macrosomia
Fetal congenital malformations
Impaired fetal growth
Pulmonary disease
Metabolic and electrolyte abnormalities
Hematologic problems
Cardiovascular anomalies
Congenital malformations

Fetal macrosomia
large for gestational
age macrosomia :
as birth weight
greater than the 90th
percentile or above
4000 g.

What is the most appropriate

pathophysiologic definition of term
macrosomic IDM?

 it was more accurate to adopt the

BW of 4000g as a practical
definition of full-term macrosomic
IDM rather than the definition with
BW>90th percentile.
Hakam Yaseen2/2001.

Fetal macrosomia
Fetal macrosomia is observed in 26% of IDMs
and in 10% of NON DM.
Macrosomia occurs among all classes of
diabetic pregnancies except those with
vasculopathy .
typically appear large and plethoric, with
excessive fat accumulation in the abdominal
and scapular regions, and visceromegaly.

Fetal macrosomia
Macrosomia in IDMs is associated with
disproportionate growth, resulting in an
increased ponderal index.
disproportionate macrosomic infants were
more likely to have hyperbilirubinemia ,
hypoglycemia, and acidosis.
fetal macrosomia may occur despite
maternal euglycemia.

Fetal macrosomia

birth injury:
shoulder dystocia.
brachial plexus injury;
clavicular or humeral
fractures.
Cephalohematoma.
subdural hemorrhage.
facial palsy

SGA \ IUGR
Impaired fetal growth may occur in as many
as 20% of diabetic pregnancies, compared
to a 10% .
Maternal vascular disease is the common
cause of impaired fetal growth.
has been associated with too tight control.

Premature delivery
Spontaneous premature labor occurs more
frequently in diabetic pregnancies
Causes:
Poor glycemic control.
associated high rate of urinary tract
infections.
Maternal preeclampsia.

Pulmonary disease
an increased risk of respiratory distress
syndrome particularly in those 38 weeks .
In contrast, fetal lung maturation may occur
early in diabetic pregnancies complicated by
vasculopathy .
transient tachypnea of the newborn.
persistent pulmonary hypertension of the
newborn.
Pnumothorax.

Metabolic \ Hypoglycemia
Definition: blood glucose levels below 40
mg/dL (2.2 mmol/L)

Metabolic \ Hypoglycemia
Hypoglycemia is caused by hyperinsulinemia due
to hyperplasia of fetal pancreatic beta cells
consequent to maternal-fetal hyperglycemia.
Because the continuous supply of glucose is
stopped after birth, the neonate develops
hypoglycemia because of insufficient substrate.
Strict glycemic control during pregnancy
decreases but does not abolish the risk of
neonatal hypoglycemia .

Metabolic \ Hypoglycemia
Hypoglycemia may present within the first
few hours .
may persist for as long as one week.
Or the neonate is asymptomatic.
such symptoms as jitteriness, irritability,
poor feeding, weak cry, hypotonia, or frank
seizure activity.

Metabolic / Hypocalcemia
definition: total serum calcium concentration of
less than 7 mg/dL (1.8 mmol/L) or an ionized
calcium value of less than 4 mg/dL (1 mmol/L )
Hypocalcemia is thought to be caused by the
lower parathyroid hormone (PTH) level.
symptoms may include jitteriness or seizure.
In term infant ,self resolving no need to tratment.

Metabolic / Hypo magnesium

Definition:serum magnesium concentration less
than 1.5 mg/dL (0.75 mmol/L
The mechanism is increased urinary loss
secondary to diabetes.
Prematurity may be a contributing factor.
the hypocalcemia may not respond to treatment
until the hypomagnesemia is corrected .

Iron deficiency
65% of all IDMs demonstrate abnormalities of iron
metabolism at birth.
Iron deficiency increases an infant's risk for
neurodevelopmental abnormalities.

Hematologic /Polycythemia
Definition: hematocrit of more than 65%
ruddy appearance, sluggish capillary refill, or
respiratory distress.
Hyperviscosity increases the risk for:
1.
2.
3.
4.

stroke
Seizure
necrotizing enterocolitis
renal vein thrombosis.

Hematologic /Thrombocytopenia
Thrombocytopenia: because of an excess of
red blood cell precursors within the bone
marrow .

Hyperbilirubinemia
Excessive red cell hemolysis, leads to
elevated bilirubin levels.
Polycythemia and prematurity also are
contributing factors

Cardiomyopathy
Hypertophic Cardiomyopathy with intraventricular
hypertrophy may occur in as many as 50% of these
infants.
Infants often are asymptomatic, but 5 to 10 percent
have respiratory distress or signs of heart failure.
Symptomatic infants typically recover after two to
three weeks of supportive care.
echocardiographic findings resolve within 6 to 12
months.

Congenital
malformations

Congenital malformations
Some speculate that may arise from an insult to
the developing mesoderm and cephalic neural
crest cells.
Metabolic disturbances, such as hyperglycemia,
hypoglycemia, and hypoxia, also may be involved.
Glucose-induced free radicals of oxygen also
have been implicated.
CVS and CNS are the most common.

Cardiovascular
These infants are at an increased risk of
congenital heart defects.
VSD
TGA

 Abu-Sulaiman RM, 2006

The most common echocardiographic findings were patent ductus
arteriosus (PDA; 70%),
patent foramen ovale (68%),
atrial septal defect (5%),
small muscular ventricular septal defect (4%),
mitral valve prolapse (2%),
and pulmonary stenosis (1%).
Hypertrophic cardiomyopathy (HCMP) was observed in 38% of cases,
mainly hypertrophy of the interventricular septum.
Severe forms of CHD encountered were D-transposition of great
arteries,
tetralogy of Fallot,
and hypoplastic left heart syndrome (1% each)..
Overall incidence of congenital heart disease was 15% after excluding
PDA and HCMP. Maternal IDDM is a significant risk factor for CHD.
Careful evaluation and early diagnosis of CHD in this high-risk group are
highly indicated. There is a need for development of prenatal screening
programs for CHD in our population.

 Overall incidence of congenital heart disease

was 15% after excluding PDA and HCMP.
Maternal IDDM is a significant risk factor for
CHD.
Careful evaluation and early diagnosis of CHD
in this high-risk group are highly indicated.
There is a need for development of prenatal
screening programs for CHD in our population

 Infant of diabetic mother presents a high risk for

cardiac involvement, either cardiac congenital
malformations (27% of cases) or acquired cardiac
pathology-hypertrophic cardiomyopathy (71% of
cases) which justifies early cardiologic screening
for all of these newborns in presence or absence
of cardiac suffering signs or symptoms.

nervous systems
the risk of anencephaly is 13 times higher.
the risk of spina bifida is 20 times higher.
microcephaly, holoprosencephaly.

Caudal regression syndrome

also referred to as caudal
agenesis, sacral dysgenesis,
or caudal dysplasia
sequence.
occurs approximately 200
times more frequently in
IDMs than in other infants.
600 times more frequently
among IDDM
The syndrome consists of a
spectrum of structural
defects of the caudal region,

Caudal regression syndrome

severe form called
sirenomelia (Mermaid
syndrome).
is a lethal abnormality.

others
Renal (eg,
hydronephrosis, renal
agenesis, ureteral
duplication).
gastrointestinal (eg,
duodenal or anorectal
atresia, small left colon
syndrome)

small left colon syndrome

a transient inability to
pass meconium .
presents as lower
bowel obstruction.
Diagnosis is made by
barium enema and
history of maternal
diabetes.

Accompanying congenital
anomalies unilateral microphthalmia.

bilateral microtia.
cleft palate.
micropenis .
unilateral cryptorchidism.
bilateral radial hypoplasia.
unilateral polydactyly.
bifid tongue.
Single umbilical artery

Management

Investigation

Glucose concentration.
Complete blood cell count.
Calcium concentration.
Magnesium concentration.
Bilirubin level.
Arterial blood gas.

Imaging
Chest radiograph
Adequacy of lung expansion, evidences
of focal or diffuse atelectasis, presence
of interstitial fluid, signs of free air in
pleural or interstitial spaces
echocardiogram

Imaging
Abdominal, pelvic, or lower extremity
radiographs
Sacral agenesis
hypoplastic femur.
defects of the tibia and the fibula, flexion
contractures of the knee and hip, or
clubfoot.

Imaging
Barium enema
Infants with feeding intolerance,
abdominal distention, nonbilious
emesis, or poor passage of meconium .
Radiologically: distal tapering of the
colon

Treatment

when

Hypoglycemia
electrolyte
respiratory
Cardiac

Before pregnancy
Better periconception control would
result in better outcome.
international recommendations for
pre-pregnancy control is glycated
haemoglobin of 7%.

During pregnancy
tight glycaemic control.
avoiding hypoglycaemia. particularly
in the first trimester and in those with
type 2.
Pre-eclampsia should be controlled.
Use of antioxident.
Avoid the flatuation in glucose level.

 Fetal macrosomia may result from episodic

rather than sustained maternal
hyperglycaemia.Reduction in blood glucose
variability may improve outcome
Seminars in Fetal & Neonatal Medicine
(2005)

around the labor

Maintain maternal glucose level at
around 4.55.5 mmol/L during
delivery.(2009)
Antenatal steroid.
Mode of delivery.

 The metabolic and blood pressure

balance is dangerously disturbed
in such pregnancies by this
treatment.( Antenatal steroid)
Arch Pediatr. 2007

After delivery
Early breast feeding.
Avoid unnecessary glucocheck.
cardiologic screening

 Establishing early breast-feeding is

paramount, since colostrum as well
as breast milk provides a generous
concentration of glucose
Mimouni F,. 1990

It appears that one half of these

episodes can be successfully
treated with enteral feedings.
Leandro Cordero, 1998

 study drew attention to the observation

that, because there is a physiological fall in
blood glucose concentration after birth,
testing for hypoglycaemia too soon (i.e.
within 60 min of birth) may result in
identifying this physiological dip in the
blood glucose concentration and therefore
unnecessary intervention.
de Rooy L, Pediatrics 2002.

 Monitor routinely plasma glucose

(before feeding) at 2,4, 6, 12, 24 and 48
h after birth.

Avoid blood glucose testing too early.

Term babies of diabetic mothers who
are otherwise well with no clinical
signs of hypoglycaemia should not
have blood glucose testing in the first
2 h after birth.
2009

Prognosis
Prognosis is very good .
Neurodevelopmental outcome
infants of mothers with poor glucose
control during pregnancy are at highest
risk for neurodevelopmental deficits.

Prognosis
Growth
Some evidence
indicates that IDMs will
have obesity as they get
older.

It might play a role in

the pathogenesis of
atherosclerosis in adult
life.
Also in developing
diabetes.

Thank you
for
your
attention