1. Neonatal Outcomes of Children Affected by Diabetes Robert Wallerstein, MD Silicon Valley Genetics Center Santa Clara Valley Medical Center

2. The incidence of congenital malformations is increased in diabetic pregnancy. What causes these unfortunate events? How can the anomalies be prevented ?

3. Diabetes affects 25.8 million people of all ages 8.3 percent of the U.S. population DIAGNOSED 18.8 million people UNDIAGNOSED 7.0 million people National Diabetes Information Center (NDIC) 2011

4. Clinical observations Incidence of gestational diabetes varies between 1 to 5% Incidence of pre-gestational diabetes varies between 0.2 and 0.3%

5. Racial and Ethnic Differences in Diagnosed Diabetes 14.2 percent of American Indians and Alaska Natives ages 20 years or older who received care from the IHS had diagnosed diabetes. After adjusting for population age differences, 16.1 percent of the total adult population served by the IHS had diagnosed diabetes, with rates varying by region from 5.5 percent among Alaska Native adults to 33.5 percent among American Indian adults in southern Arizona. After adjusting for population age differences, 2007–2009 national survey data for people ages 20 years or older indicate that 7.1 percent of non-Hispanic whites, 8.4 percent of Asian Americans, 11.8 percent of Hispanics/ Latinos, and 12.6 percent of non-Hispanic blacks had diagnosed diabetes. Among Hispanics/Latinos, rates were 7.6 percent for both Cuban Americans and for Central and South Americans, 13.3 percent for Mexican Americans, and 13.8 percent for Puerto Ricans. Compared with non-Hispanic white adults, the risk of diagnosed diabetes was 18 percent higher among Asian Americans, 66 percent higher among Hispanics/Latinos, and 77 percent higher among non-Hispanic blacks. Among Hispanics/Latinos compared with non- Hispanic white adults, the risk of diagnosed diabetes was about the same for Cuban Americans and for Central and South Americans, 87 percent higher for Mexican Americans, and 94 percent higher for Puerto Ricans.

6. Mother 25 yo G4 P2103 Prenatal care was limited HbA1c 11.7 in first trimester HbA1c 7 at term

7. Level II ultrasound showed: ventriculomegaly Shortening of the long bones Cleft lip and palate Polyhydramnios

8. Delivery via C-section at 36 4/7 weeks Apgar 5 and 8 Transferred to NICU CPAP of 5 Admission diagnoses: LGA Respiratory distress Multiple anomalies including: bilateral cleft lip and palate, skeletal dysplasia, and anteriorly placed anus

10. Discharge Diagnoses at day of life 43:congestive heart failure on diuretics Coarctation of the aorta VSD and PFO Bilateral cleft lip and palate Skeletal dysplasias Anteriorly placed anus Acqueductal stenosis with stable ventriculomegaly Ureteropelvic junction stenosis with left hydronephrosis GE reflux MRSA colonization

12. Skeletal survey –Pelvic rami not fused –Hypoplasia of acetabular shaft –Under development of pelvis –Sacrum shows fusion of 2 vertebrae and is disorganized –Shortening and bowing of the femurs

17. Diabetes in pregnancy Pregnancy loss Congenital anomalies Macrosomia Neonatal, Childhood, and Adult complications

18. Pre-conception care and glycemic control can lower the rate of congenital malformations Malformation rate is 2% among registered pre-conception mothers vs 10% for post- conception group Only 30-60% of pre-gestational diabetes women are in care

19. Prevalence of major congenital malformations is 3 to 5 times higher than non-diabetic women. Congenital anomalies are the most common cause of perinatal death in these infants

20. Anomalies associated with Diabetes Cardiovascular Central nervous system Musculoskeletal Caudal regression syndrome also called sacral agenesis is 200 to 400 times more frequent in diabetic mothers ( but still arre)

21. Most pregnancies are not recognized until two or more weeks after conception Strict glycemic control has not begun until after critical period of organogenesis and embryogenesis have begun.