Volume I: Issue 1 Perinatal Connection

Quarterly Newsletter of Perinatal Practice at:

Volume I: Issue 1

Perinatal Connection

JULY 2018

Immense progress has been made in the care of maternal diabetes in the last several decades. Diabetes in pregnancy not only affects newborns but has lasting effects on maternal health equally. Early diagnosis, regular follow-up and strict glucose control during preconception and antenatal period can significantly reduce associated maternal and neonatal morbidities.

Diabetes & PregnancyDiabetes affects approximately 14% of pregnancies in the United States. Gestational diabetes is one of 3 types of diabetes and is identified only during pregnancy and is similar to Type 2 diabetes in that the body produces insulin but is not able to respond to insulin normally. During pregnancy, most patients with diabetes have gestational diabetes (80-87%), 7% haveType 2 diabetes and the remainders have Type 1 diabetes.

Risk factors that increase the probability for a woman to be diagnosed with gestational diabetes include:• Ethnicity- Hispanics and African Americans • Family History of Type 2 diabetes• Obesity• Previous pregnancy with gestational diabetes

Diagnosis - Diabetes during pregnancy is diagnosed using two step testing between 24-28 weeks of gestation. In the first step, patients will drink 50g of glucose and have their blood glucose checked an hour later. Blood glucose should be less than 135mg/dl at the one-hour check otherwise the patient should proceed to step two. Different facilities may use a different cutoff value.

The lower the value, the greater the likelihood of identifying at risk patients. Here on the border, we have a high rate of diabetes of all types (Table 1) and so we use a lower number to be sure that we identify patients who may need help. The second step consists of a drink of 100g of glucose and blood glucose checks prior to the drink and at one, two and three

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Effects of Diabetes on Pregnancy and Fetus

Knowledge is defined as facts, information, and skills acquired by a person through experience or education; the theoretical or practical understanding of a subject. What better way to avail ourselves than through opportunities like the Perinatal Connection. – Dr. Garrett Levin, Division Chief, NICU, El Paso Children’s Hospital/Texas Tech Physicians of El Paso

Healthy children need healthy mothers. This principle forms the foundation of the work we do. -Dr. Lisa Moore, Division Chief, Maternal Fetal Medicine, University Medical Center of El Paso/Texas Tech Physicians of El Paso

Sharing knowledge, exchanging ideas and reviewing difficult, complex cases are all important steps to improving perinatal quality and making an impact on the healthcare of mothers and their babies. - Dr. Sireesha Reddy, Chair, General Obstetrics and Gynecology, University Medical Center of El Paso/Texas Tech Physicians of El Paso

There is no one giant step that does it. It’s a lot of small steps. Perinatal Connection is our small step forward to improve perinatal education and care in our region. – Dr. Sanjeet Panda, Founder/Co-Editor of Perinatal Connection, Neonatologist, El Paso Children’s Hospital/Texas Tech Physicians of El Paso

Introduction to Perinatal Connection:

Fig 1- Classic Caudal Regression (Syringomyelia), severe compli-cation of poorly controlled diabetes during pregnancy. (Photo courtesy of Dr. Lisa Moore)

hours after. The second step should be done while fasting. Two abnormal values make the diagnosis.

Management - Controlling blood glucose is essential for a healthy pregnancy. Patients with Type 1 and Type 2 diabetes are encouraged to control blood glucose prior to pregnancy to improve outcomes. An A1C of 6% or less is the goal. Hyperglycemia is a known teratogen. Patients with high blood glucose at the time of conception are at risk for fetal anomalies in several body systems. Congenital heart defects and anomalies of the genitourinary tract are the most common. Once a diagnosis of diabetes during pregnancy is made, the patient should check her blood glucose four times a day; first thing in the morning i.e. fasting, and either one or two hours after each meal. The fasting value should be no higher than 95mg/dl and one hour after meals should be less then140mg/dl and 2 hours should be 120mg/dl. Patients with Type 1 Insulin Dependent Diabetes Mellitus (IDDM) will need to check pre- and post- meal blood glucose to correctly administer insulin, but the goals remain the same.

Diabetes during pregnancy is managed using diet, exercise and as a last resort, medication. Here in the Borderland, patients typically have a high carbohydrate diet with tortillas and rice. One serving of carbohydrate is 15 grams. That’s the amount of carbohydrate in one 6-inch flour tortilla. It is recommended to eat 3 meals and 3 snacks each day broken down as below:• Breakfast 2-3 carbohydrate servings (30-45g) + protein• Lunch 3-4 carbohydrate servings (45-60g) + protein• Dinner 3-4 carbohydrate servings (45-60g) + protein• Snacks- no more than one carbohydrate serving (15g) but protein is better.

All patients are encouraged to read labels and to become aware of how much carbohydrate they are eating. Just because something doesn’t taste sweet doesn’t mean it won’t raise blood glucose levels. We have a dedicated Diabetes in pregnancy clinic. In that clinic we request that all patients keep a food diary in addition to the blood glucose log. Thirty minutes of walking or other moderate exercise per day is a good way to control blood glucose. If a change to the diet and the addition of exercise doesn’t achieve the desired level of blood glucose control, we will add medication. Insulin is considered the gold standard because it controls blood glucose and does not cross the placenta, so it has no fetal effect.

There are several formulations of insulin available. We typically use rapid acting insulin at meal times combined with an intermediate acting insulin for basal coverage. Oral agents are a second option for management of blood glucose. Both metformin and glyburide have been extensively studied. Oral medications have the added benefit of ease of use which enhances compliance and they are usually cheaper than insulin.

What’s New There are new non-insulin injectables on the market that are Glucagon-like peptide 1 (GLP-1) agonists. GLP-1 is a hormone that causes Beta cells to release insulin. This class of drugs has been approved for treatment of Type 2 diabetes. They have not been studied in pregnancy. (References available upon request)

Dr. Lisa Moore is Professor and Maternal-Fetal Medicine Division Chief at Texas Tech University Health Sciences Center El Paso [email protected]

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Join us for an unforgettable evening to showcase local culinary excellence and raise funds to help March of Dimes continue the fight to end premature birth. The El Paso Signature Chefs will take place Thursday, September 13 at Epic Railyard. Sponsorships and tickets can be purchased through www.signaturechefs.org/event/elpasotx

Contact – Jennifer Torres (Development Manager) – [email protected]

Help Raise Funds To Ensure Healthier Local Births


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The primary mechanism of neonatal effects is maternal hyper-glycemia, which leads to fetal hyperglycemia and hyperinsulin-emia. These effects can be classified into early and long-term effects. Fig. 2

Early effectsDiabetic Fetopathy – Maternal Diabetes can lead to significant fetal anomalies involving all major organs. Excess fetal insulin levels result in elevated metabolic rates that lead to increase oxygen consumption and fetal hypoxemia. Fetal hypoxemia increases risk for mortality, metabolic acidosis and increases erythropoiesis resulting in polycythemia (5%).

Respiratory Diseases (5%) - Transient tachypnea and respiratory distress syndrome occur in infant of Diabetic Mother (IDM) due to two major reasons - more likely to be born preterm and fetal hyperinsulinemia impeding surfactant synthesis [1]. This can lead to need for endotracheal intubation and ventilator support for severe cases in the early phase of life, while most will need some form of non-invasive respiratory support like nasal cannu-la or continuous positive airway pressure (CPAP) in the NICU.

Macrosomia (45%) which is defined as birth weight > 4000 g or greater than 95 percentiles for gestation is more common in IDM due to excess of nutrient delivery to fetus from poorly con-trolled diabetic mother causes increased fetal growth, especially in insulin sensitive tissues which includes liver, muscle, cardiac muscle, and subcutaneous fat.

Severe and long standing maternal diabetes can also lead to poor in-utero transfer of nutrients leading to impaired fetal growth, resulting in small for gestation or intrauterine growth restriction (5%). Fetal hyperglycemia along with oxidative stress during fetal life increases risk for abnormal cardiac muscle re-modeling and hypertrophic cardiomyopathy (15%) [2].

Birth Injury rates are increased in IDM due to shoulder dystocia, that is directly related to the severity of Macrosomia. Shoulder dystocia increases the risk of brachial plexus injury, clavicular or

humeral fractures, and perinatal asphyxia. Less commonly, can also lead to cephalohematoma, subdural hemorrhage, or facial palsy. All the above leads to increased admission to NICU and can have significant long term effects.

Neonatal Hypoglycemia (25%) is a result of abrupt stoppage of high maternal glucose supply to the newborn and high newborn plasma insulin level. The onset of hypoglycemia is within few hours of life. These infants require close blood sugar monitor-ing, requiring glucose supplementation including intravenous dextrose infusion. This is the most common reason for admis-sion to Neonatal Intensive care units across nation and in El Paso Children’s Hospital. Management of Hypoglycemia remains controversial but current management in our hospital is based on algorithm recommended by America Academy of Pediatrics [3] Fig. 3 (source: AAP Guideline)

Fig. 3Metabolic complications (4%) commonly associated with IDM include hypocalcemia and hypomagnesaemia at birth. Hypocal-cemia in term and other healthy IDMs usually is asymptomatic and resolves without treatment. As a result, routine screening is not recommended. The serum calcium concentration should be measured in symptomatic infants and in those with prematurity, asphyxia, respiratory distress, or suspected infection.

Hypomagnesemia, defined as serum magnesium concentration less than 1.5 mg/dL (0.75 mmol/L), occurs in within the first three days after birth. Low neonatal levels are due to maternal hypomagnesemia caused by increased urinary loss secondary to diabetes, along with premature birth. Hypomagnesemia usually is transient and asymptomatic and, thus, usually is not treat-ed. However, hypomagnesemia can reduce both parathyroid hormone (PTH) secretion and PTH responsiveness and as result hypomagnesemia should be corrected in infants with symptom-atic hypocalcemia first.

Newborn Effects: Infant of Diabetic Mother (IDM)


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Congenital anomalies - IDMs are at significant risk for major congenital anomalies due to maternal hyperglycemia at the time of conception and during early gestation. The overall reported risk for major malformations is about 5 to 6 percent with a high-er prevalence rate of 10 to 12 percent when mothers require in-sulin therapy. Anencephaly and spina bifida are 13 and 20 times more frequent, vertebral anomalies, cleft palate, and intestinal anomalies such as small colon syndrome are also more likely to occur in IDMs than in infants of nondiabetic mothers. Caudal regression syndrome is a rare severe manifestation in IDMs, consists of a spectrum of structural defects of the caudal region, including incomplete development of the sacrum and, to a lesser degree, the lumbar vertebrae (Fig 1)

Long-term effectsAbnormal metabolic control during pregnancy puts the infant at risk for poor neurodevelopment outcome. The altered maternal metabolism also increases incidence of obesity, impaired glucose tolerance, blunted insulin secretion, and hypertension develop-ing during adolescence and persists into adult life. The lifelong

risk of developing type 1 diabetes is 2 percent in offspring of a mother with type 1 diabetes, 6 percent in siblings, and 65 per-cent by age 60 years in identical twins (versus 0.3 to 0.4 percent in subjects with no family history). [4]

ConclusionThe list of complications associated with diabetes in general population is long and these effects are magnified during preg-nancy, not only harmful for mother’s health but also her infant. Preconception and pregnancy period control of diabetes can significantly reduce adverse effects. A multidisciplinary collabo-ration between maternal-fetal medicine, obstetrics and pediat-rics is paramount in achieving best outcome for diabetic mother and her newborn. (References available upon request) Dr. Ajay Singh, FAAP Board Certified Neonatologist Assistant Professor, Texas Tech University Health Sciences Center El Paso [email protected]

Perinatal ConnectionEditorial Board....................................................................................................Sanjeet Panda, MD, FAAP, Neonatologist, EPCH, TTP El PasoLisa Moore, MD, Maternal Fetal Medicine, UMC, TTP El PasoSadhana Chheda, MD, FAAP, Neonatologist, EPCH, TTP El Paso

Patricia Rojas-Mendez, MD, OBGYN, UMC, TTP El PasoZuber Mulla, PhD, Faculty Development, TTUHSC EL PasoRuth Samble, PNP, NICU at EPCH, TTP El PasoRyan Mielke, MPA, Director of Public Affairs, UMCAudrey Garcia, Marketing, EPCHLaura Gonzalez, RN, MSN, EPCH NICU Nurse Manager

We are interested in providing you with a newsletter that is relevant and of interest to you. Please contact us with perinatal topics you would like to see addressed. For a copy of our newsletter or to be placed on our mailing list, contact us via email at: [email protected].

Annual Symposium in El Paso Planned for Sept. 14 , 2018

For further details about the symposium, please contact:Cynthia Ogaz at (915) 215-4880

Email - [email protected]

Volume I: Issue 1 Perinatal Connection

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