Presenter Disclosures

Sneha Sood (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

“No relationships to disclose”

Maternal Diabetes and Its Effects on the Newborn

Sneha Sood, MD Assistant Professor, John A. Burns School of Medicine Neonatologist, Kapi’olani Medical Center and Hilo Medical Center

Definitions of Maternal Diabetes

Maternal Hyperglycemia Defects in Insulin secretion, insulin action, or both

Classification of Maternal Diabetes

Type I: Insulin-dependent Type II: Noninsulin-dependent Gestational diabetes – A1: onset during pregnancy requiring diet treatment only – A2: onset during pregnancy requiring insulin treatment

Statistics

3-5% of pregnancies complicated by diabetes 80-90% due to gestational diabetes

Risks for Diabetes Type I and II

Type I – Genetic – White Type II – Genetic – Asian, Hispanic, Native and African American groups – Obesity – Lifestyle – Hypertension – Elevated cholesterol – Increased age – Hx of gestational diabetes

Gestational Diabetes

Even “mild” gestational diabetes associated with adverse outcomes Women with gestational diabetes have an increase risk of developing type II diabetes Some evidence that the offspring have increased risk of obesity, glucose intolerance, and diabetes in young adulthood Risk can be eliminated by control of blood sugar during pregnancy Because of presentation later in pregnancy not associated with birth defects; other complications can occur.

Risk factors for GDM

Age > 25 years Obesity First degree relative with diabetes Ethnicity (Hispanic, Native American, Asian, African American) Hx of abnormal glucose Hx of previous GDM Glucocorticoid therapy

Hawaii Data

Hawaiian, Filipinos, and Japanese at highest risk Statewide prevalence 6-9%; native Hawaiians 20.4% (age-adjusted)* Gestational Diabetes in approximately 14% of pregnancies.

Study by Silva et al* – Kapi’olani Medical Center data (1995-2005)* – GDM in approximately 4.8% pregnancies – GDM 3.6% in Native Hawaiian/Pacific Islander, 6.5% for Filipino women, 6.4% for Chinese Women, 5.5% for Japanese women, 2.3% in Caucasian women.

– Rates may have been affected by exclusion criteria, age of patient population, how prevalence calculated and other factors.

*Silva et al, Diabetes Care, 2006

Effects on Newborn

Hypoglycemia Macrosomia IUGR Hyperbilirubinemia Respiratory distress Congenital malformations Septal hypertrophy of heart Hypocalcemia Small left colon Hyperviscosity Fetal distress/fetal demise

Hypoglycemia

Hyperinsulinism with interrupted supply of maternal glucose May be severe and persist for several days May require IV fluids and higher than normal dextrose solutions; sometimes require placement of central line for management

Macrosomia

Macrosomia

Incidence of 25-45% in pregnancies complicated by diabetes; 8-14% in the general population Believed to be due to increased maternal glucose concentrations which cross the placenta and result in increased fetal insulin levels. Associated enlargement of other organs including liver, heart, adipose tissue, adrenals, and pancreatic islet tissue. Increase risk of birth injuries and asphyxia due to shoulder dystocia Increases risk for C-section delivery Controlling maternal blood glucose will decrease but not eliminate the risk of macrosomia

Brachial Plexus Injury

IUGR

Babies born to mothers with severe diabetes and vascular compromise may also have babies that are small due to decreased uterine blood flow.

5000 4500 4000 3500 Weight (grams) 3000 2500 2000 1500 1000 500 Large for Gestational Age Low Birthweight Appropriate for Gestational Age Small for Gestational Age Very Low Birthweight 24 26 28 30 32 34 36 Gestation (weeks) 38 Preterm 40 Term 42 44 Post Term 90th Centile 10th Centile

Hyperbilirubinemia

Increased red blood cell mass Immature liver

Respiratory Distress

Glucose and insulin affect surfactant system Higher incidence of respiratory distress syndrome when matched to controls of same gestational age. Persistent pulmonary hypertension Transient tachypnea of the newborn

Premature Baby with RDS

Congenital Malformations

Incidence of malformations is 5-10%; 2-4x greater that of non-diabetic mothers Elevated glucose has teratogenic effects Defects occur during first trimester No malformations in mothers with gestational diabetes because this occurs during third trimester Other factors may influence the presence of malformations Malformations include: – CNS defects (including anencephaly and spina bifida) – Cardiac defects – Genitourinary – Limb defects

This is a complication of maternal diabetes. It occurs 200-400 x more often in babies born to mothers with diabetes. However caudal regression is rare. Congenital heart disease and neural tube defects more common.

Cardiomyopathy

Hypertrophy of the cardiac septum Reversible May be complicated by heart failure

Other Effects

Hypocalcemia: effect on neonatal PTH, calcitonin, and other possible causes Small left colon: Immature GI motility?

Hyperviscosity: ?due to hypoxia, stimulation of erythropoiesis – Increased red blood cell mass – Potential for venous thrombosis

Access to Medical Care

Control of maternal blood glucose is crucial in preventing or decreasing complications Therefore, prenatal care very important in the management of pregnant women with diabetes, regardless of type Prenatal care difficult to obtain because of physician shortages, especially on the Island of Hawaii.

Health Professional Shortage Areas Derived from Hawaii Health Information Corporation Website

Prematurity, Prenatal Care, and Teen birth Rates in Hawaii National Hawaii State Island of Hawaii Prematurity* 12.2% 12.8% 13.3% Late/no PNC* 3.6% 3.7% 5.8% Teen birth rate*** 2.21%** 2.0%*** 3.3%

*2001-2003: derived from Peristats, March of Dimes Website ** Births for teens age 17 and under in 1999-2004 (derived from State of Hawaii Primary Needs Assessment Data Book 2005, Family Health Services Division, Hawaii Dept. of Health ***Birth data for 15-17 year olds 2004 (derived from National Vital Statistics Report Website)

Number of Deliveries on the Island of Hawaii 2006

Hilo Medical Center

1117

North Hawaii Community Hospital Kona Hospital

536 547

Number of Obstetricians

Oahu: 161 Island of Hawaii: 12* Maui: 12 Kauai: 6.5** Island of Hawaii Hilo: 4.5

N. Hawaii: 2* Kona: 4.5 *Does not include midwives **1.0 FTE locum tenems coverage *Midwives: 5, 3 do hospital work

Pediatrician: Patient Island of Hawaii*

Hilo – Pediatricians: 9 North Hawaii – Pediatricians: 5 Kona – Pediatricians: 6 Hilo area: 1:2513 North Hawaii: 1:1114 Kona: 1:1696 *Kau area not included in distribution and Bay Clinic not included in Pediatrician count

Population 2006

Hawaii State 1,285,498 Oahu Island of Hawaii Maui 909,863 171,191 141,320 Kauai 63,004

Derived from U.S. Census Bureau Quick Facts

Island of Hawaii Population 2005

County of Hawaii Databook, 2006

Hilo (North and South), Hamakua, Puna 90,463 North and South Kohala 22,281 North and South Kona 40,720 Kau 6,443