Transcript The Infant of a Diabetic Mother

The Infant of a Diabetic Mother
Pathology, Clinical Presentation and Management
of an IDM
SIKANDER ADENI, MD; FAAP
Medical Director - NICU, UMCB, Austin, TX
OBJECTIVES
• Discuss briefly the effects of maternal
Diabetes on the Fetus
• Review the morbidities encountered in an IDM
• Discuss the management of an IDM in the
nursery
• Discuss the prognosis for an IDM and review
the follow up needed after hospital discharge
Diabetes Mellitus
A chronic metabolic disorder
involving complete or decreased
insulin secretion or other insulin
dysfunction resulting in increased
serum glucose concentration
Diabetes Worldwide
• 366 million diabetics by
2030
• Latin America, India and
Africa- diabetic prevalence
increases by 150%
• 80 % of diabetics will live in
low and middle income
countries
• 20.8 million diabetics in the
US- 75% of pop in 2005
• Prevalence may increase by
50 %
• 8 % of women >20y have
Diabetes
• Pregestational diabetes
higher in minority women
esp. native Americans
Diabetes- ADA Classification
• Type 1: IDDM (Juvenile diabetes)- early onset, lack of insulin,
presence of antibodies against B-cells; insulin needed,
ketoacidosis seen.
• Type 2: NIDDM( Adult diabetes, Maturity onset)- older
patients, insulin resistance common, decreased insulin
sensitivity, overweight patients, significant genetic
component.
• Gestational Diabetes : Carbohydrate intolerance with onset or
first recognition during pregnancy
• Other causes: eg GK mutation, Drug induced, CF, organ
transplantation
WHITE’S CLASSIFICATION
• A – Diagnosis of diabetes before pregnancy
• B- Age of onset >20 y OR duration <10 y, no vascular
involvement
• C- Onset at 10-19 y OR duration 10-19 y
• D- Onset at <10 y OR duration >20 y , HTN or
background
retinopathy
• E- Calcification of pelvic arteries
• F- Nephropathy
• H- Atherosclerotic heart disease
• R- Proliferative retinopathy or vitreous He
• T- After Renal transplantation
Morbidities in Infants of Diabetic Mothers
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Macrosomia
Hypoglycemia
RDS
IUGR
Hypocalcemia
Hyperbilirubinemia
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Congenital Anomalies
Polycythemia
Hyper viscosity
Cardiomyopathy
Increased fetal death
Postnatal problems
Mechanisms of fetal morbidities
Inc FFA
& AA
Maternal
Diabetes
? Congenital
Malformations
Maternal
hyperglycemia
Macrosomia
Increased O2
consum+ hypoxia
Fetal
hyperglycemia
Fetal hyper insulinemia
Neonatal
hypoglycemia
RDS
Macrosomia
• Common Definition: Infant
with Bwt >4000 grams
and/or Head Circumference
& Length > 90th percentile .
• IDMs have increased fat
cells and fat cell
hypertrophy.
• Excess non-fatty tissue in
shoulders and scapular
areas.
Macrosomia
• ¼ th of insulin
dependent mothers
have Macrosomic
infants
• Excess growth happens
in 3rd trimester.
• GDM mothers have
same incidence of
Macrosomic infants as
other diabetics
Macrosomia- Complications
• Birth Injuries- Brachial
Plexus injury, Fracture
Clavicle or Humerus, Facial
n. injury, Cephalhematoma.
• Shoulder Dystocia (2-4 fold
more)
• Hypoglycemia
• Increased risk for asphyxia
• Increased recurrence risk in
mother.
Macrosomia
Morbidities- Congenital Anomalies
• Upto 4-fold increase in infants of IDDMs
• Malformations shown to occur before 8th
week of gestation.
• Etiology: not clear, ? Hyperglycemia. ? Glucose
as a teratogen.
Congenital Anomalies
• Many reported
• Most common are CV, Musculo-Skeletal & CNS
• Incidence decreased with tight glucose control
in mothers
Sacral Agenesis
Types of Sacral Agenesis
Respiratory Distress Syndrome
• Increased risk of RDS in IDMs <37 weeks GA
• Possible insulin interference with surfactant
composition and delayed maturation of
surfactant system
• L/S ratio unreliable. PG better
Metabolic Complications
• Hypoglycemia
• Hypocalcemia
• Hypomagnesemia
Hypoglycemia
• Occurs in upto 25 % of IDMs
• Half of hypoglycemia occurs in first 24 hours
• Less likely when mother’s glucose tightly
controlled
• Maybe asymptomatic
• Pedersen Hypothesis
Hypocalcemia & Hypomagnesemia
• Occur in 50% or more of IDMS born to mothers who
are IDDM
• Decreased PTH secretion in IDMs
• IDMs may have decreased calcium transfer
• Decreased Mg++ levels in mothers
• ? Decreased Mg++-Decreased PTH
Polycythemia/ Hyperbilirubinemia
• Fetal hypoxiaPolycythemiaHyperbili
• ? Ineffective RBC Production
• Polycythemia may lower glucose levels
• May be associated with RVT
Management of IDMs
• Delivery:
Consider as high risk
Follow basic steps of resuscitation for infant
Management
• Post-delivery Observe / Evaluate for:
Asphyxia
Birth injury
Malformations
Macrosomia
Hypoglycemia
Respiratory Distress
Management of Hypoglycemia
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Maybe asymptomatic
Can occur is 30 minutes
May last upto 48 hrs or more
Check BG ASAP after birth and at regular
intervals for 48 hrs
• Glucose protocol: Q3-6 checks X 48 hrs
• Early feeds
• BG < 30 mg/dl IV dextrose recommended
Treatment Algorithm
Hypoglycemia
Symptomatic
Asymptomatic
Early feeds
IV Mini bolus + IVF
BG < 45
BG in 30 min, then q
1h until >45
BG > 50 mg x 6-8 hrs,
wean IVF, start feeds
BG > 45
Continue
monitoring and
advance feeds
Minibolus
Prognosis
• IDMs 10 x more likely to be obese (1960)
• Macrosomic infants 6X likely to be obese at
age 7 (Vohr 1980)
• Increased risk for teenage obesity
• Increased risk for glucose intolerance as young
adults (19%)
• No developmental problems noted in
asymptomatic hypoglycemic infants
Follow up for the IDM
• Developmental risk:
• CP , seizures 3-5 X common. SGA IDM infants
have increased risk for cognitive delay at 3-5
years.
• Metabolic Risk:
• IDMs with 1 parent Type DM have 1-6 % risk
of DM themselves