Download Infant of a Diabetic Mother Review of Newborn Implications

Infant of a
Diabetic Mother
Review of Newborn Implications
Jamie Haushalter, CPNP-PC Newborn Nursery
Emily Freeman, CPNP-PC Newborn Nursery
Erin Burnette, NP-C Newborn Nursery
Purpose and Objectives
• Review pathophysiology of diabetes in pregnancy and
implications for the newborn
• Apply “Up to Date” Information to practice.
• The learner will be able to
• Identify at least 3 neonatal complications associated with being an
infant of a diabetic mother.
• Explain the pathophysiology of increased incidence of respiratory
distress in the IDM infant.
Types of Diabetes
Preconception Diabetes
• Type 1 or Type II Diabetes
• 1.8 percent prevalence
• Usually diagnosed if fasting
glucose ≥92 or random glucose
≥200.
• Hgb A1C ≥6.5%
Gestational Diabetes
• Diabetes first diagnosed
during pregnancy.
• 2-25% prevalence
• Glucose tolerance test btw
24-28wks
• 1hr (50g): ≥130 with 99%
sensitivity and 77% specificity
• 1hr (50g): ≥140 with 85%
sensitivity and 86% specificity
Gestational Diabetes: Classifications
• The White Classification system is used to differentiate
between gestational diabetes and diabetes that existed prior
to pregnancy. Gestational diabetes is class A with the
following subclassifications:
• A1GDM: diet controlled
• A2GDM: medication controlled with insulin versus oral antihyperglycemic agents
• Insulin is recommended therapy, as oral anti-hyperglycemics are not
approved for treatment of GDM, however they are often used.
• Oral anti-hyperglycemic agents that are sometimes used:
• Glyburide: studies have not shown an increased risk of excessive neonatal
hypoglycemia with this medication.
• Metformin: Often provides less control of maternal blood sugars than insulin or
glyburide.
Maternal Diabetes Results in Fetal
Complications….WHY?
• In first trimester, hyperglycemia can lead to SAB or birth
defects, more commonly in pregestational diabetes.
• In the 2nd and 3rd trimesters, diabetic ‘fetopathy’ begins to
occur.
• Higher levels of glucose and insulin in the mother causes fetal
hyperglycemia, hyperinsulinemia, and macrosomia which can
lead to neonatal complications.
• Greater risk of birth injuries: shoulder dystocia, clavicle
fracture, brachial plexus injury, cephalohematoma, asphyxia
Neonatal Complications
• Congenital anomalies
• Metabolic abnormalities
• Prematurity
• Polycythemia
• Perinatal asphyxia
• Low iron stores
• Macrosomia
• Hyperbilirubinemia
• Respiratory distress
• Cardiomyopathy
“Fetopathy”
• Caused by
Chronic fetal
increased
hyperinsulinemia
metabolic
demands
O2 consumption,
• Caused by
fetal hypoxemia,
placental
erythropoiesis
insufficiency
Polycythemia?HTN and cardiac
hypertrophy
• Fetal
Complicationstill birth
Neonatal Complications
• Congenital Anomalies
• Heart malformations are
present in 3-9% of diabetic
pregnancies
• Most common heart defects seen
in infants of diabetic mothers:
• Transposition of the great
arteries
• Double outlet right ventricle
• Ventricular septal defect
• Truncus arteriosus
• Tricuspid atresia
• Patent ductus arteriosus
• Neural tube defects, intestinal
complications, and orthopedic
anomalies also more common.
• Risk of anomalies reduced by
tight maternal glycemic control
• Prematurity
• Due to both medically indicated
and spontaneous deliveries.
• Women with diabetes are more
at risk for delivering early,
however mechanism is unclear.
• May be related to preeclampsia,
developing macrocomia,
nephropathy, poor glycemia
control, and risk of late fetal
death.
Neonatal Complications
•
Perinatal Asphyxia
•
Increased metabolic rate, leading to
increased oxygen consumption and
fetal hypoxemia, as placenta cannot
keep up with demands.
•
Macrocomia can make delivery
difficult, increased risk of shoulder
dystocia.
•
Cardiomyopathy leading to
abnormalities in fetal heart rate.
•
Macrosomia
• Maternal elevated sugars cause
increased growth of the fetus,
especially in insulin sensitive tissues
(SQ fat, cardiac muscle, liver).
• Elevated insulin levels in the fetus
stimulates glycogen storage in the
liver, increased lipid synthesis, and
accumulation of fat.
• Infants have bigger head:chest and
shoulder:head ratios, more body fat,
and visceromegaly.
• Disproportionate macrosomia
increases the risk of
hyperbilirubinemia, hypoglycemia,
metabolic acidosis, and respiratory
distress.
Neonatal Complications
•
Respiratory Distress
• Common complication in infants
born to diabetic mothers because
maternal hyperglycemia delays
surfactant synthesis and can lead to
impaired or delayed lung
maturation.
• Increased risk of neonatal
respiratory distress syndrome
• 2-3 times more likely to have
Transient Tachypnea of the
Newborn (TTN)
• Hypothesized to be caused by delayed
fluid clearance in the diabetic fetal
lung
• C-sections more common in this
population which also increases risk
of TTN
•
Metabolic Abnormalities
• Hypoglycemia
• Defined as BG <40, onset usually
within the first few hours of birth
• Commonly occurs in macrosomic
infants because of continued
hyperinsulinemia even after being
removed from their intrauterine
glucose supply, even 2-4 days.
• Strict maternal glucose control can
reduce the risk but does not
eliminate the possibility of
hypoglycemia in the newborn.
• SGA infants also at risk because of
decreased glycogen stores and
hyperinsulinemia decreases the
ability to mobilize hepatic glycogen.
Neonatal Complications: Metabolic
Abnormalities
• Hypocalcemia
• Hypomagnesemia
• Serum Ca <7mg/dL
• Serum Mg level <1.5/dL
• Occurs in 5-30% in IDMs
• 40% of IDMs within the first 3
days after birth.
• Good maternal glycemic control
reduces risk
• Infants usually asymptomatic
and resolves without treatment,
therefore routine screening not
recommended.
• Consider measuring in
symptomatic infants: jittery,
apnea, tachypnea, lethargy,
seizures.
• Thought to be due to low
maternal levels from urinary
loss secondary to diabetes.
• Usually transient and
asymptomatic therefore no need
to screen unless clinical concern.
Neonatal Complications
• Polycythemia
• Increased erythropoietin
concentrations caused by
chronic fetal hypoxemia
• Polycythemia can lead to
hyperviscosity syndrome and
vascular sludging (if severe can
cause ischemia and infarction or
organs)
• Low iron stores
• Inversely related to degree of
polycythemia.
•
With hypoxemia, fetus has
increased red cell mass, which
causes iron redistribution,
leading to iron deficiency in
developing fetal organs 
cardiomyopathy,
neurodevelopmental problems,
etc.
•
As extra red cells are eventually
broken down, the iron will be
recirculated, so supplementation
is not necessary.
• Check hematocrit within 12
hours of birth
• One study showed 17% on IDMs
had Hcts> 60 and 5% >65
Neonatal Complications
•
Hyperbilirubinemia
• 11-29% of IDMs
• Associated with prematurity, poor
maternal glycemic control,
macrosomia and polycythemia
•
Cardiomyopathy
• Increased risk of transient
cardiomyopathy thought to be
caused by fetal hyperinsulinemia
increasing the synthesis and
deposition of fat and glycogen in
myocardial cells.
• Decreases size of ventricles,
possibly obstructing outflow of the
left ventricle.
• Infants with cardiomyopathy are
often asymptomatic, however 510% will have respiratory distress
or signs of poor cardiac output.
• Congestive cardiomyopathy rare.
Management of the Infant of a Diabetic
Mother
• Lab testing for hypoglycemia and polycythemia.
• Glucose monitoring within 1-2 hours after birth and with symptoms.
Should be preprandial and continue for the first 12-24 hours of life.
• Check hematocrit 12 hours after birth.
• Assess for cardiac and respiratory disease if cyanosis present.
• Monitor for jaundice
• If symptomatic, consider calcium and magnesium levels.
Outcomes
• Genetic susceptibility for development of diabetes, especially
if mother has type 1.
• 2% risk if mom has type 1 diabetes versus 0.4% if mother did not
have diabetes.
• With type 2 diabetes, a first degree relative has a 5-10x higher
chance of developing T2DM.
• Risk for increased BMI, obesity, and impaired glucose
metabolism due to intrauterine exposure to hyperglycemia
and fetal hyperinsulinemia.
• If maternal diabetes is poorly controlled, risk of
developmental abnormalities in the infant, especially if head
circumference was small or if mother had higher ketone
levels in the 2nd and 3rd trimesters.
Thank you for
caring for our
“cupcake”
babies!
References
http://www.uptodate.com/contents/infant
-of-a-diabetic-mother
http://www.uptodate.com/contents/scree
ning-and-diagnosis-of-diabetes-mellitusduring-pregnancy?source=see_link
Thank you!