presentation concerning the effects of maternal hyperglycemia on the fetus and neonate

1. Effects of Maternal
Hyperglycemia on the fetus
and neonate
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Khorfakkan Hospital
Sharjah, UAE
anahbaghdad@gmail.com

2. Effects of Maternal Hyperglycemia on the
fetus
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 2

3. Congenital Anomalies
• A major threat to IDMs is the possibility of a life-threatening
structural anomaly
• In the normoglycemic pregnancy, the risk of a major birth defect is
1% to 2%.
• Among women with pregestational diabetes, the risk of a fetal
structural anomaly is fourfold to eightfold higher
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 3

4. Cont.
• Major congenital anomalies occurred in 4.6% overall with :
 4.8% for type 1 diabetes mellitus
 4.3% for type 2 diabetes mellitus.
• Neural tube defects in IDM were increased 4.2-fold
• Congenital heart disease were increased 3.4-fold
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 4

5. Neural tube defects
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 5
https://en.wikipedia.org/wiki/Neural_tube_defect

6. Cont.
• There is no increase in birth defects among offspring of:
 Diabetic fathers
 Nondiabetic women
 Women in whom gestational diabetes develops after the first
trimester.
• Adverse outcome was significantly higher in the poor control group
(HbA1c ≥7.5) than in the fair control group (HbA1c <7.5), with a ninefold
increase in the congenital malformation rate (2)
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 6

7. Prevention
• Because the critical period for teratogenesis is the first 3 to 6 weeks
after conception, normal glycemic control must be instituted before
pregnancy to prevent these birth defects
• Any elevation of the HbA1c above normal increases the risk of
teratogenesis proportionately.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 7

8. Macrosomia
• Fetal overgrowth is a major problem in pregnancies
complicated by diabetes, leading to:
 Unnecessary cesarean sections
 Potentially avoidable birth injuries
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 8

9. Cont.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 9
http://emedicine.medscape.com/article/262679-overview

10. Definition
• Macrosomia is defined variously as birth weight above the
90th percentile for gestational age or birth weight greater
than 4000 g
• It occurs in 15% to 45% of diabetic pregnancies.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 10

11. Cont.
• Excessive fetal size contributes to a greater frequency of:
 Intrapartum injuries:
 Shoulder dystocia
 Brachial plexus palsy
Asphyxia
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 11

12. 7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 12
Lateral traction to the head occurs when the baby’s head is pulled sideways in an attempt to
dislodge the trapped shoulder. Once the dystocia occurs, no lateral traction should be applied to
the baby’s head.
http://www.shoulderdystociaattorney.com

13. Brachial plexus palsy
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 13
http://www.sciencedirect.com/science/article/pii/S0146000514000275

14. Prevention
• Measures that promote consistent maternal euglycemia
may prevent macrosomia
• Strict maternal glycemic control using insulin and dietary
therapy and fastidious blood glucose monitoring can
reduce the incidence of macrosomia
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 14

15. Fetal Hypoxic Stress
• Episodic maternal hyperglycemia promotes a fetal
catabolic state in which oxygen depletion occurs.
• Profound episodic hyperglycemia in the third trimester
causing severe fetal hypoxic stress
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 15

16. Perinatal Complications of Diabetes
During Pregnancy
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 16

17. Perinatal Mortality
• Perinatal mortality rates among women with diabetes remain
approximately twice those observed in nondiabetic women
• Most perinatal deaths in contemporary diabetic pregnancy are due
to:
 Congenital malformations
 RDS
 Extreme prematurity
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 17

18. Birth Injury
• Birth injury, including shoulder dystocia and brachial plexus trauma,
is more common among IDMs, and macrosomic fetuses are at the
highest risk
• Shoulder dystocia occurs in 0.3% to 0.5% of vaginal deliveries
among normal pregnant women; the incidence is twofold to fourfold
higher in women with diabetes.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 18

19. Polycythemia and Hyperviscosity
• Polycythemia (defined as central venous hemoglobin concentration
>20 g/dL or hematocrit >65%) is not uncommon in IDMs and is
apparently related to glycemic control.
• Hyperglycemia is a powerful stimulus to fetal erythropoietin
production, probably mediated by decreased fetal oxygen tension
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 19

20. Cont.
• Neonatal polycythemia may promote:
 Vascular sludging
 Ischemia
 Infarction of vital tissues, including the kidneys and central
nervous system.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 20

21. Neonatal Hypoglycemia
• Approximately 15% to 25% of neonates delivered from women with
diabetes during gestation will develop hypoglycemia during the
immediate newborn period
• It is usually much milder and less common in the infant of a
woman:
 Whose insulin-dependent diabetes is well controlled throughout
the entire pregnancy
 Who exhibits euglycemia during labor and delivery.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 21

22. Cont.
• Unrecognized postnatal hypoglycemia can lead to:
 Neonatal seizures
 Coma
 Brain damage
• it is imperative that the nurseries receiving IDMs have a protocol for
frequent monitoring of the infant’s blood glucose level until
metabolic stability is ensured.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 22

23. Hyperbilirubinemia
• The risk of hyperbilirubinemia is higher in IDMs than in normal infants.
• There are multiple causes of hyperbilirubinemia in IDMs, but prematurity
and polycythemia are the primary contributing factors.
• Increased destruction of red blood cells contributes to the risks of
jaundice and kernicterus.
• This complication is usually managed using phototherapy, but exchange
transfusions may be necessary for marked bilirubin elevations.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 23

24. 7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 24
Infant with acute advanced bilirubin encephalopathy
http://accesspediatrics.mhmedical.com/content.aspx?bookid=528&sectionid=41538477

25. Hypertrophic and Congestive
Cardiomyopathy
• IDMs with cardiomegaly may have either congestive or
hypertrophic cardiomyopathy
• Echocardiograms show a hypercontractile, thickened myocardium,
often with septal hypertrophy disproportionate to the ventricular free
walls.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 25

26. 7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 26
http://www.mayoclinic.org/diseases-conditions/hypertrophic-cardiomyopathy/home/ovc-20122102
Septal hypertrophy

27. Cont.
• Maternal insulin-like growth factor-1 (IGF-1) is significantly
elevated among neonates with asymmetrical septal hypertrophy (1)
• B-type natriuretic peptide, a marker for congestive cardiac failure, is
elevated in neonates whose mothers had poor glycemic control
during the third trimester.(2)
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 27
1.Hayati A.R., Cheah F.C., Tan A.E., et al: Insulin-like growth factor-1 receptor expression in the placentae of diabetic and normal pregnancies. Early
Hum Dev 2007; 83: pp. 41-46
2.Halse K.G., Lindegaard M.L., Goetze J.P., et al: Increased plasma pro-B-type natriuretic peptide in infants of women with type 1 diabetes. Clin
Chem 2005; 51: pp. 2296-2302

28. Cont.
• IDMs can also have congestive cardiomyopathy without
hypertrophy.
• Echocardiography shows the myocardium to be overstretched and
poorly contractile
• This condition is often rapidly reversible with correction of neonatal
hypoglycemia, hypocalcemia, and polycythemia; it responds to
digoxin, diuretics, or both.*
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 28
* Jaeggi E.T., Fouron J.C., and Proulx F.: Fetal cardiac performance in uncomplicated and well-controlled maternal type I diabetes.
Ultrasound Obstet Gynecol 2001; 17: pp. 311-315

29. Cont.
• Treatment of hypertrophic cardiomyopathy with an inotropic or
diuretic agent tends to further decrease the size of the ventricular
chambers and leads to obstruction of blood flow.
• Routine fetal echocardiogram in diabetics has not been proved to
be cost-effective or to improve outcomes*
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 29
*Bernard L.S., Ramos G.A., Fines V., et al: Reducing the cost of detection of congenital heart disease in fetuses of women with
pregestational diabetes mellitus. J Ultrasound Obstet Gynecol 2009; 33: pp. 676-682

30. Respiratory Distress Syndrome
• Respiratory dysfunction in the newborn IDM continues to be a common
complication of diabetic pregnancy
• In a diabetic pregnancy, however, it is unwise to assume that the risk of
respiratory distress has passed until after 38.5 weeks’ gestation*
• Any delivery contemplated before 38.5 weeks’ gestation for other than the
most urgent fetal and maternal indications should be preceded by
documentation of pulmonary maturity through amniocentesis.
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 30
Moore T.R.: A comparison of amniotic fluid fetal pulmonary phospholipids in normal and diabetic pregnancy. Am J Obstet Gynecol
2002; 186: pp. 641-650

31. 7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 31
https://radiopaedia.org/articles/respiratory-distress-syndrome

32. References
• Macintosh M.C., Fleming K.M., Bailey J.A., et al: Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales,
and Northern Ireland: population based study. BMJ 2006; 333: pp. 177
• Temple R., Aldridge V., Greenwood R., et al: Association between outcome of pregnancy and glycaemic control in early pregnancy in type 1 diabetes: population
based study. BMJ 2002; 325: pp. 1275-1276
• Athukorala C., Crowther C.A., and Willson K.: Women with gestational diabetes mellitus in the ACHOIS trial: risk factors for shoulder dystocia. Aust N Z J Obstet
Gynaecol 2007; 47: pp. 37-41
• Alam M., Raza S.J., Sherali A.R., et al: Neonatal complications in infants born to diabetic mothers. J Coll Physicians Surg Pak 2006; 16: pp. 212-215
• Hayati A.R., Cheah F.C., Tan A.E., et al: Insulin-like growth factor-1 receptor expression in the placentae of diabetic and normal pregnancies. Early Hum Dev 2007;
83: pp. 41-46
• Halse K.G., Lindegaard M.L., Goetze J.P., et al: Increased plasma pro-B-type natriuretic peptide in infants of women with type 1 diabetes. Clin Chem 2005; 51: pp.
2296-2302
• Jaeggi E.T., Fouron J.C., and Proulx F.: Fetal cardiac performance in uncomplicated and well-controlled maternal type I diabetes. Ultrasound Obstet Gynecol 2001;
17: pp. 311-315
• Bernard L.S., Ramos G.A., Fines V., et al: Reducing the cost of detection of congenital heart disease in fetuses of women with pregestational diabetes mellitus. J
Ultrasound Obstet Gynecol 2009; 33: pp. 676-682
7/31/2017Effects of Maternal Hyperglycemia on the fetus and neonate Prof. Dr. Saad S Al Ani 32

33. Presenter Media