The Infant of a Diabetic Mother

Islamic University Nursing college

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:

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.

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.

Diabetes Mellitus

A chronic metabolic disorder involving

complete or decreased insulin secretion

or other insulin dysfunction resulting in

increased serum glucose concentration.

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

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

Morbidities in Infants of Diabetic Mothers

• Macrosomia• Hypoglycemia• RDS• IUGR• Hypocalcemia• Hyperbilirubinemia

• Congenital Anomalies• Polycythemia• Hyper viscosity• Cardiomyopathy• Increased fetal death• Postnatal problems

Macrosomia• Common Definition: Infant with

Bwt >4000 grams and/or Head

Circumference & Length > 90th

percentile .

• IDMs have increased fat cells

and fat cell hypertrophy.

• Excess non-fatty tissue in

shoulders and scapular areas.

Macrosomia• ¼ th of insulin dependent mothers

have Macrosomic infants.

• Excess growth happens in 3rd

trimester.

• GDM mothers have same

incidence of Macrosomic infants as

other diabetics.

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.

Morbidities- Congenital Anomalies

• Upto 4-fold increase in infants of IDDMs

• Malformations shown to occur before 8th week of gestation.

• Etiology: not clear, ? Hyperglycemia. ? Glucose as a teratogen.

Congenital Anomalies

• Many reported.

• Most common are CV, Musculo-Skeletal & CNS.

• Incidence decreased with tight glucose control in mothers.

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

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.

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

Polycythemia/ Hyperbilirubinemia

• Fetal hypoxiaPolycythemia hyperbilirubinemia

• ? Ineffective RBC Production

• Polycythemia may lower glucose levels

Management of IDMs

• Delivery:

Consider as high risk. (mother & infant)

Follow basic steps of resuscitation for infant.

Management

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

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.

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.

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