1. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Sneha Sood “No relationships to disclose”

2. 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

3. Definitions of Maternal Diabetes Maternal Hyperglycemia Defects in Insulin secretion, insulin action, or both

4. 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

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

6. 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

7. 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.

8. 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

9. 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

10. Effects on Newborn HypoglycemiaMacrosomiaIUGRHyperbilirubinemia Respiratory distress Congenital malformations Septal hypertrophy of heart Hypocalcemia Small left colon Hyperviscosity Fetal distress/fetal demise

11. 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

12. Macrosomia

13. 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

14. Brachial Plexus Injury

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

16. Weight (grams) Gestation (weeks) 2426283032343638404244 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 Term Post Term Preterm 90th Centile 10th Centile Large for Gestational Age Appropriate for Gestational Age Low Birthweight Very Low Birthweight Small for Gestational Age

17. Hyperbilirubinemia Increased red blood cell mass Immature liver

18. 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

19. Premature Baby with RDS

20. 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

21. 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.

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

25. 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

26. 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.

27. Health Professional Shortage Areas Derived from Hawaii Health Information Corporation Website

28. 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)

29. Number of Deliveries on the Island of Hawaii 2006 Hilo Medical Center 1117 North Hawaii Community Hospital 536 Kona Hospital 547

30. 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

31. Pediatrician: Patient Island of Hawaii* 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 Hilo –Pediatricians: 9 North Hawaii –Pediatricians: 5 Kona –Pediatricians: 6

32. Population 2006 Hawaii State 1,285,498 Oahu909,863 Island of Hawaii 171,191 Maui141,320 Kauai63,004 Derived from U.S. Census Bureau Quick Facts

33. 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 Kau6,443