1. The Infant of a Diabetic Mother Islamic University Nursing college

2. The Infant of a Diabetic Mother Is infant born to a mother with diabetes or gestational diabetes, severity of the problem depend on the severity of maternal diabetes. Altered physiology: hyperinsulinemia in utero secondary to decreased epinephrine and glucose response result in the following in the infant:

3. Altered physiology Amount of body fat. Hypoglycemia can occur immediately or within 2-12 hours post delivery. IDM may symptomatic or not with blood glucose below 20 mg/dl. Hypocalcemia: associated with prematurity, difficult labor and or asphyxia at birth, can occur during first 24-48 h after birth. Birth trauma such as cephallhematom due to large size of infant.

4. Altered physiology cont… Hyperbilirubinemia: occur 48-72 h due to immature liver and inability to conjugate bilirubin. Prematurity or SGA associated with placental insufficiency. Respiratory problems may occur. Polycythemia: HCT more than 65% or Hb% 22gm/dl, which the risk of thrombosis, RDS, hypoglycemia & hypocalcemia. Congenital anomalies: (cardiac & skeletal). Infection.

5. Diabetes Mellitus A chronic metabolic disorder involving complete or decreased insulin secretion or other insulin dysfunction resulting in increased serum glucose concentration.

6. Diagnostic criteria Family or mother history of DM. Determine gestational age. Blood studies: Blood glucose, HCT, Hb%, blood gases, bilirubin, electrolytes. Clinical manifestations: Marcosomia, cardiomegaly, hepatomegaly, abundent fatty, hair, vernix caseosa May SGA

7. 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

8. Morbidities in Infants of Diabetic Mothers Macrosomia Hypoglycemia RDS IUGR Hypocalcemia Hyperbilirubinemia Congenital Anomalies Polycythemia Hyper viscosity Cardiomyopathy Increased fetal death Postnatal problems

9. Macrosomia Common Definition: Infant with Bwt >4000 grams and/or Head Circumference & Length > 90 th percentile. IDMs have increased fat cells and fat cell hypertrophy. Excess non-fatty tissue in shoulders and scapular areas.

10. Macrosomia ¼ th of insulin dependent mothers have Macrosomic infants. Excess growth happens in 3 rd trimester. GDM mothers have same incidence of Macrosomic infants as other diabetics.

11. Macrosomia- Complications Birth Injuries- Brachial Plexus injury, Fracture Clavicle or Humerus, Facial nerve injury, Cephalhematoma. Shoulder Dystocia (2-4 fold more) Hypoglycemia Increased risk for asphyxia Increased recurrence risk in mother.

12. Morbidities- Congenital Anomalies Upto 4-fold increase in infants of IDDMs Malformations shown to occur before 8 th week of gestation. Etiology: not clear, ? Hyperglycemia. ? Glucose as a teratogen.

13. Congenital Anomalies Many reported. Most common are CV, Musculo-Skeletal & CNS. Incidence decreased with tight glucose control in mothers.

14. Respiratory Distress Syndrome Increased risk of RDS in IDMs <37 weeks GA Possible insulin interference with surfactant composition and delayed maturation of surfactant system Metabolic Complications Hypoglycemia Hypocalcemia Hypomagnesemia

15. Hypoglycemia Occurs in up to 25 % of IDMs. Half of hypoglycemia occurs in first 24 hours. Less likely when mother’s glucose tightly controlled. May be asymptomatic.

16. Hypocalcemia & Hypomagnesemia Occur in 50% or more of IDMS born to mothers who are IDDM Decreased parathormone or parathyrin hormon ( PTH) secretion in IDMs IDMs may have decreased calcium transfer Decreased Mg++ levels in mothers ? Decreased Mg++-  Decreased PTH

17. Polycythemia/ Hyperbilirubinemia Fetal hypoxia  Polycythemia  hyperbilirubinemia ? Ineffective RBC Production Polycythemia may lower glucose levels

18. Management of IDMs Delivery: Consider as high risk. (mother & infant) Follow basic steps of resuscitation for infant.

19. Management Post-delivery Observe / Evaluate for: Asphyxia. Birth injury. Malformations. Macrosomia. Hypoglycemia. Respiratory Distress.

20. Management of Hypoglycemia May be asymptomatic Can occur within 30 minutes. May last up to 48 hrs or more. Check Blood Glucose as soon as possible after birth and at regular intervals for 48 hrs. Early feeds. Blood Glucose < 30 mg/dl IV dextrose recommended.

21. Prognosis IDMs 10 x more likely to be obese (1960) Macrosomic infants 6 X 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.

22. 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 2DM have 1-6 % risk of DM themselves