Infant Of Diabetic Infant Of Diabetic MotherMother

LALEH GHANEI,MD,LALEH GHANEI,MD,Endocrinology Endocrinology

Fellow,Endocrinology Research Fellow,Endocrinology Research Center Taleghani HospitalCenter Taleghani Hospital

Most Common Most Common Problem In IDMSProblem In IDMS

RDSRDS HypoglycemiaHypoglycemiaHypocalcemiaHypocalcemia

HyperbilirubinemiaHyperbilirubinemiaHeart failure, CardiomegalyHeart failure, Cardiomegaly

PolycitemiaPolycitemiaRenal vein trombosisRenal vein trombosis

Hypercoaguloability StateHypercoaguloability StateSepsisSepsis

PrematurityPrematuritySmall Left Colon SyndromeSmall Left Colon Syndrome

MacrosomiaMacrosomia

Macrosomia is one of the most commonly mentionedproblems associated with GDM

The reported incidence of macrosomia (4000 grams) in women with GDM is 16%–29%, as opposed to a 10% rate in women without GDM.

maximum of 12% of macrosomia could be explained by maternal GDM. The rest was due to maternal age, weight, and parity.

with macrosomia there might be an increase in cesarean

deliveries, instrumental deliveries (forceps and ventouse

deliveries), birth trauma such as brachial plexus injury or

clavicular fracture, or neonatal hypoglycemia.

Hyperbilirubinemia  Hyperbilirubinemia  Hyperbilirubinemia occurs in 11 to 29 percent of Hyperbilirubinemia occurs in 11 to 29 percent of

IDMsIDMs Jaundice is associated with poor maternal glycemic control, and macrosomic infants are at highest risk

Polycythemia and prematurity also are contributing factors.

The mechanism is thought to be increased hemolysis

The excess hemolysis may result from glycosylation of erythrocyte membranes.

  Hypomagnesemia, defined as serum magnesium Hypomagnesemia, defined as serum magnesium concentration less than 1.5 mg/dL (0.75 mmol/L) concentration less than 1.5 mg/dL (0.75 mmol/L)

Hypomagnesemia  Hypomagnesemia 

occurs in up to 40 percent of IDMs within the first three days after birth

The mechanism is thought to be maternal hypomagnesemia caused by increased urinary loss secondary to diabetes.

Prematurity may be a contributing factor.

Polycythemia and Polycythemia and hyperviscosity syndrome  hyperviscosity syndrome 

  Polycythemia, defined as a central venous Polycythemia, defined as a central venous hematocrit of more than 65 percent, has been hematocrit of more than 65 percent, has been described in described in 13 to 33 percent of IDMs13 to 33 percent of IDMs

The mechanism for polycythemia is uncertain but, as mentioned above, may be related to increased erythropoietin concentrations caused by chronic fetal hypoxemia

Transfusion of placental blood to the fetus associated with maternal or fetal distress also may contribute to the high hematocrit

Polycythemia and Polycythemia and hyperviscosity syndrome hyperviscosity syndrome

Polycythemia may lead to hyperviscosity Polycythemia may lead to hyperviscosity syndrome, including vascular sludging, syndrome, including vascular sludging, ischemia, and infarction of vital organs. ischemia, and infarction of vital organs.

Hyperviscosity is thought to contribute to the increased incidence of renal vein thrombosis seen in IDMs.

To detect polycythemia, the hematocrit should be measured within 12 hours of birth.

    Hypocalcemia  Hypocalcemia    Hypocalcemia, defined as a total serum calcium Hypocalcemia, defined as a total serum calcium

concentration of less than 7 mg/dL (1.8 mmol/L) concentration of less than 7 mg/dL (1.8 mmol/L) or an ionized calcium value of less than 4 mg/dL or an ionized calcium value of less than 4 mg/dL (1 mmol/L) (1 mmol/L) occurs in at least 10 to 20 percent of IDMs and up to 50 percent in some series

The lowest serum calcium concentration typically occurs between 24 to 72 hours after birth and often is associated with hyperphosphatemia.

    Hypocalcemia  Hypocalcemia 

The extent of hypocalcemia is related to The extent of hypocalcemia is related to the the severity and duration of maternal severity and duration of maternal diabetes. diabetes. Hypocalcemia is thought to be caused by the lower parathyroid hormone (PTH) concentrations after birth in IDMs compared to normal infants Higher serum ionized calcium concentrations in utero in IDMs may suppress the fetal parathyroid glands The development of hypomagnesemia, prematurity, and birth asphyxia may be contributing factors.

Hypocalcemia  Hypocalcemia  Hypocalcemia in term IDMs usually is Hypocalcemia in term IDMs usually is

asymptomatic and resolves without treatment. asymptomatic and resolves without treatment. routine screening is not recommended. However, the serum calcium concentration should be measured in infants with jitteriness, lethargy, apnea, tachypnea, or seizures, and in those with prematurity, asphyxia, respiratory distress, or suspected infection.

Hypoglycemia  Hypoglycemia  Hypoglycemia, defined as blood glucose levels Hypoglycemia, defined as blood glucose levels

below 40 mg/dLbelow 40 mg/dL (2.2 mmol/L), occurs frequently (2.2 mmol/L), occurs frequently in IDMs in IDMs (27 percent in one large series) (27 percent in one large series)

The onset typically occurs in the first few hours after birth and requires close monitoring.

Hypoglycemia is most common in macrosomic infants

Hypoglycemia  Hypoglycemia  this incidence is related to this incidence is related to persistent persistent

hyperinsulinemiahyperinsulinemia in the newborn after in the newborn after interruption of the intrauterine glucose supply interruption of the intrauterine glucose supply from the mother from the mother A potentiating factor is the depressed response to hypoglycemia of counterregulatory hormones, such as glucagon and catecholamines, in IDMs

Strict glycemic control during pregnancy decreases but does not abolish the risk of neonatal hypoglycemia

there is evidence that neonatal hypoglycemia is much more related to macrosomia per se than to maternal GDM

In a study by Jensen et al an increased rate of hypoglycemia is reported of 24% in babies of mothers with GDM compared to 0% in negative controls. However, this was a retrospective study and could be suffering from bias,

The most important question is: do these metabolic problems really have any permanent negative consequences for the babies’ long-term health?It appears that adequately treated hyperbilirubinemia probably has no lasting effects on the infant

long-term damage due to neonatal hypoglycemia seems limited to those few cases with hypoglycemic seizures or recurrent hypoglycemia

Respiratory distress Respiratory distress syndrome  syndrome 

  Respiratory distress syndrome (RDS) occurs Respiratory distress syndrome (RDS) occurs more frequently in more frequently in IDMs of White classifications IDMs of White classifications A, B, and CA, B, and C than in normal infants at each than in normal infants at each gestational age, especially before 38.5 weeks gestational age, especially before 38.5 weeks

The mechanism may be delayed maturation of surfactant synthesis caused by hyperinsulinemia, possibly by interference with the induction of lung maturation by glucocorticoids

Intrauterine growth Intrauterine growth restriction restriction

  IUGR can occur in IDMs, especially when IUGR can occur in IDMs, especially when diabetes is complicated by diabetes is complicated by vasculopathy (White's vasculopathy (White's class F and aboveclass F and above) ) Preeclampsia, a frequent complication of diabetic pregnancies, can further impair growth by impeding flow of blood and nutrients to the fetus.

Congenital anomalies associated with diabetic pregnancies also may lead to IUGR.

Intrauterine growth Intrauterine growth restriction restriction

Although close control of maternal glucose limits Although close control of maternal glucose limits the development of macrosomia, the development of macrosomia, excessively excessively aggressive glucose controlaggressive glucose control may lead to growth may lead to growth restriction. restriction.

In one series, diabetic women with postprandial glucose concentration less than 130 mg/dL (7.3 mmol/L) had infants who were small for gestational age more often than those with values above this level (18 versus 1 percent)

The neonate should be observed closely after delivery for respiratory distress.

Capillary blood glucose should be monitored at 1 hour of age and before the first four breast feedings (and for up to 24 hours in high- risk neonates).

The cut-off of 44mg% (2.6 mmol/l) is now currentlyused as the working definition for hypoglycemia. This“Operational threshold” is not a diagnosis of a disease but an indication for action

If the baby is obviously macrosomic, calcium and magnesium levels should be checked on day 2.

Breastfeeding, as always, should be encouraged in women with GDM.

RISK OF DEVELOPING RISK OF DEVELOPING DIABETES  DIABETES 

  IDMs have an increased IDMs have an increased risk of risk of developing diabetesdeveloping diabetes

A similar relationship has been noted with obesity as offspring of diabetic women, even those who are of normal birth weight, have a higher mean weight relative to height up to

5 to 19 years of age than do offspring of nondiabetic and prediabetic women .

The prevalence of DMII in women previously diagnosed

with GDM is higher compared to those without GDM in

their earlier pregnancies

the children of mothers with GDM are also at risk for DMII

and obesity later in life

Occasionally an increased risk for neuropsychological

problems has been reported in these children

NEURODEVELOPMENTAL NEURODEVELOPMENTAL OUTCOME  OUTCOME 

The neurodevelopmental outcome of infants of The neurodevelopmental outcome of infants of well-controlled diabetic mothers is similar to that well-controlled diabetic mothers is similar to that of normal infants. of normal infants.

poorly controlled diabetes may result in developmental abnormalities in the offspring.

head circumference at three years of age was negatively correlated with HbA1c levels during pregnancy; furthermore, smaller head circumference was associated with poorer intellectual performance