NEWBORN OF A DIABETIC MELITUS

MOTHER

MIRITI M.D
MASTER OF CLINICAL MEDICINE; ACCIDENTS AND
EMERGENCY
MCM/2017/73494
FACILITATORS: DR SIMBA
DR MBURUGU
 Objectives
• Introduction
• Epidemiology
• Pathophysiology
• Clinical Manifestations
• Work up & Management
• Prognosis
 Introduction
• Women with diabetes in pregnancy (type 1, type 2,
and gestational) are at increased risk for adverse
pregnancy outcomes.
• Adequate glycemic control before and during
pregnancy is crucial to improving outcome.
• Diabetic mothers have a high incidence of
polyhydramnios, preeclampsia, pyelonephritis,
preterm labor, and chronic hypertension;
• Their fetal mortality rate is greater than that of
nondiabetic mothers especially after 32 wk of
gestation.
•Fetal loss throughout pregnancy is associated with
poorly controlled maternal diabetes (especially
ketoacidosis) and congenital anomalies.
•Most infants born to diabetic mothers are large
for gestational age.
•If the diabetes is complicated by vascular disease,
infants may be growth restricted, especially those
born after 37 wk of gestation.

•The neonatal mortality rate is >5 times that of

infants of nondiabetic mothers and is higher at all
gestational ages and in every birthweight for
gestational age category
 Epidemiology
• Harmful effects of maternal diabetes recognized
more than 100 years ago.
• Since development of specialized maternal, fetal, and
neonatal care for women with diabetes and their
offspring; a nearly 30 fold decrease in morbidity and
mortality has been noted.
• Currently worldwide 3-10% of pregnancies affected
by abnormal glucose regulation and control.
• Majorly GDM about 80-88%.
• For the preexisting diabetes (about 12-20%); type 1
accounts for about 35%, while type 2 about 65%
Infants born to mothers with glucose
intolerance are at an increased risk of
morbidity and mortality related to the
following:
•Respiratory Distress
•Growth abnormalities (LGA/ SGA)
•Hyperviscosity secondary to Polycythemia
•Congenital malformations
•Hypocalcemia
•Hypomagnesemia
•Iron abnormalities
Pathophysiology
 Large, plump, plethoric infant of a mother with gestational
diabetes.

Source: Figure 107-2 Nelson Textbook of pediatrics 20th Edition (Black& white)
 Clinical Manifestations
• Neonates large and plump as a result of increased
body fat and enlarged viscera, with puffy, plethoric
facies resembling that of patients who have been
receiving corticosteroids.
• May be of normal or low birthweight, particularly if
they are delivered before term or if their mothers
have associated vascular disease.
• Hypoglycemia develops in approximately 25-50% of
infants of diabetic mothers and 15-25% of infants of
mothers with gestational diabetes, but only a small
percentage of these infants become symptomatic.
 NEONATAL HYPOGLYCEMIA
• Level of blood glucose low enough to cause symptoms
• CNS/autonomic: jitteriness, tremors, convulsions,
limpness, lethargy, eye-rolling, diaphoresis, hypothermia,
high-pitched cry
• RESPIRATORY: cyanosis, tachypnea, apnea
• CVS: pallor, cardiac failure/arrest
• GI/nutrition: feeding difficulty
*note: 1. All inter-related! 2. Symptoms can be seen
with other diagnoses, so always keep a differential in
mind, consider other diagnoses if glucose administration
does not improve symptoms
Source: Canadian Pediatric Society (CPS) Position
Statement: 2015
•The infants tend to be jittery, tremulous, and hyper
excitable during the 1st 3 days after birth, although
hypotonia, lethargy, and poor sucking may also occur.
•They may have any of the diverse manifestations of
hypoglycemia. Early appearance of these signs is more
likely to be related to hypoglycemia, and their later
appearance to hypocalcaemia;
these abnormalities may also occur together.
•Perinatal asphyxia may produce similar signs.
Hypomagnesemia may be associated with
the hypocalcaemia. These manifestations may also
occur in the absence of hypoglycemia, hypocalcaemia,
and asphyxia.
 Clinical manifestations: Respiratory
• Respiratory Distress Syndrome (RDS)
– Occurs more frequently in IDMs
– Hyperinsulinemia causes delayed maturation of surfactant
synthesis
Diabetic moms likely to go into premature labor hence greater
risk of having immature lungs at birth
• Transient Tachypnea of the Newborn (TTN)
– Occurs more frequently in IDMs because of risk factors
associated with having diabetes: Prematurity, Macrosomia,
Birth asphyxia, Polycythemia& Increased likelihood of c-
section
– Caused by delayed resorption of fetal lung fluid, mild
pulmonary immaturity, and mild surfactant deficiency
– Usually resolves by 72 hours of life
 Clinical Features- Cardiovascular Sys
• Hypertrophic cardiomyopathy
– Most infants are asymptomatic, but 5-10% have respiratory
distress, other signs of poor cardiac output, or heart failure
– Usually resolves by 6 months of age
– Thought to be caused by hyperinsulinemia, which increases fat
and glycogen deposition into myocardial cells, causing
thickening of Intraventricular septum &/or ventricular walls
• Cardiac Anomalies
– Poor diabetic control in the 1st trimester is associated with an
increased risk of congenital malformations
– 2/3 of congenital anomalies are cardiovascular or CNS related.
– Common cardiac anomalies: Transposition of the great
arteries, ASD, VSD, aortic coarctation
 Neurologic
CNS anomalies
Anencephaly and spina bifida occur 12-20x
more frequently in IDMs
Caudal Regression Syndrome: incomplete
development of the lumbar and sacral
vertebrae
 occurs 200x more frequently in IDMs
 spectrum of structural defects possible
 associated with neurologic impairment due
to involvement of distal spine
 GI and GU
• GI anomalies
–Situs inversus, atresias, small left colon
syndrome: presents like Hirschsprung
disease, but innervation of the bowel is
normal, inability to pass meconium
resolves spontaneously
• GU anomalies
–Renal agenesis and other urinary tract
abnormalities
 Hematologic
• Polycythemia
– Intervention required when central hematocrit > 65 with
symptoms or >70 when asymptomatic
– Occurs in 13-33% of IDMs
– Related to hypoxia in utero -> stimulates erythropoietin, which
increases RBC production
– Hyperviscosity in vasculature can cause sludging, ischemia, and
infarction of internal organs
• Hyperbilirubinemia
– Occurs in 11-29% of IDMs
– Risk factors include:
• Prematurity
• Birth injury resulting in bruising or cephalohematoma
• Polycythemia causing increased hemolysis and release of bilirubin
 Birth Injury
• Macrosomia puts infant at risk for injuries during
delivery:
• Shoulder dystocia can lead to:
-Clavicular and/or humeral fractures
-Brachial plexus injuries
• Traumatic delivery or need for vacuum/forceps
assistance can lead to:
-Cephalhematoma
-Facial bruising
-Facial nerve injuries
 Work-Up and Management
• Follow blood sugars
• If SGA or LGA, also check hematocrit
• Further work-up and management depends on
patient’s clinical presentation and physical exam
– Hypoglycemia – early feeding or IVFs with dextrose
– Symptomatic electrolyte abnormalities – replete electrolytes
– Respiratory distress – Cardiopulmonary support, CXR/echo
to search for cause
– Hyperbilirubinemia – phototherapy
– Polycythemia – IVF hydration or exchange transfusion
– Neuro/GI/GU anomalies – imaging studies, specialist consult
 Prognosis
• Morbidity and mortality lessen with
adequate diabetes control during
pregnancy
• If diabetes is poorly controlled, there is a
higher risk of neurodevelopment deficits
• The risk of CP and epilepsy is increased
• The risk of childhood obesity, diabetes,
and metabolic syndrome is increased
 REFERENCES
• Canadian Pediatric Society (CPS) Position Statement
on Neonatal Hypoglycemia: 2015
• Harris DL, Weston PJ, Harding JE: Incidence of
neonatal hypoglycemia in babies identified as at
risk, J Pediatr 161:787–791, 2012.
• Nelson Textbook of Pediatrics 20th Edition, Chapter
107.
• Rozance PJ, Hay WW Jr: Neonatal hypoglycemia—
answers, but more questions, J Pediatr 161:775–
776, 2012.