A male infant was delivered via elective C-section at 36 weeks and 5 days gestation due to the mother's history of two previous C-sections. The infant presented with hypoglycemia which is common in infants of diabetic mothers. The infant was admitted to the NICU for monitoring and treatment of hypoglycemia, including intravenous fluids and corticosteroids. After several days of blood sugar monitoring and treatment, the infant's blood sugars stabilized and he was discharged.

1. case A Male baby UA @ 36 +5 weeks gestational age delivered on 10-9-2011 through Elective LSCS under s/a due to prev.2 c.sections. Baby cried spontaneously after birth Apgar score at 1min. 5/10 and 5 min.8/10

2. ANTENATAL HISTORY Booked patient: Mother age: 35 year Mother's blood group B +ve Gestational age of baby 36 +5 weeks G3 P2 A0 Cousin marriage No h/o HTN,D.M.,HEPATITIS or any other illness to mother found. h/o G.D.M. & insulin R_16M,16E 2 other siblings (1 male,1 female) are alive & healthy .

3. GENERAL PHYSICAL EXAMINATION Birth wt. 3.1 kg Heart rate 164/min. RR 68/min. G.Appearance: p.cyanosis Eyes Normal Femoral pulses b/l palpable Fontanel normal (open)

4. RESPIRATORY SYSTEM NVB b/l equal chest movements On Auscultation: b/l equal air entry b/l clear chest

5. CARDIO VASCULAR SYSTEM S 1 + s 2 + 0

6. GIT Soft abdomen Non distended No visceromegaly BS +Ve

7. CENTRAL NERVOUS SYSTEM Neonatal reflexes present Moro +ve Grasping +ve Sucking +ve

8. EXTERNAL GENITALIA Grossly normal penis & urethra B/l descendent testes Anus Patent

9. BSR after Birth 38 mg/dl

10. DIFFERENTIAL DIAGNOSIS Infant of diabetic Mother Hypoglycemia

11. Baby admitted to NICU: Kept on Warmer Temperature maintained Baseline investigation sent Oral feed trial BSR monitoring 1 hrly

12. Hb 15.5mg/dl Tlc 11900 RBC 5.12 Plt 356000 Mcv 99 Mch 3o Mchc 31

13. INVESTIGATIONS: DLC: Polymorphs 44% Lymphocytes 48% Monocytes 04% Eosinophils 04%

14. S Calcium 9.5mg/dl Blood sugar random 18mg/dl Baby's blood group A+ve

15. X Ray Chest Normal

16. 1 hr BSR MONITORING 10/09/11 4.oo p.m 36 mg/dl 5.oo p.m 52 mg/dl 6.oo p.m 74 mg/dl 7.oo p.m 96 mg/dl 8.oo p.m 83 mg/dl 9.oo p.m 56 mg/dl 1o.oo p.m 72 mg/dl 11.oo p.m 46 mg/dl oo.oo a.m 84 mg/dl

17. 11/09/11 2.oo a.m 110 mg/dl 4.oo a.m 55 mg/dl o6.oo a.m 63 mg/dl o8.oo a.m 47 mg/dl o9.oo a.m 57 mg/dl inj.solucortef i/v 8hrly started 1o.oo a.m 60 mg/dl 12.oo p.m 78 mg/dl o4.oo p.m 70 mg/dl o8.oo p.m 92 mg/dl

18. oo.00 a.m 96 mg/dl 12/09/11 04.Oo a.m 92 mg/dl O8.oo a.m 88 mg/dl Monitoring stopped Discharged …………..

19. DIAGNOSIS Infant Of Diabetic Mother

20. What is IDM Infant of a diabetic mother is a BABY born to a mother who has Diabetes.

21. Types of diabetes in pregnancy Gestational diabetes Pre existing diabetes

22. Physiology of glucose control in IDM Maternal hyperglycemia Glucose, amino acid but not insulin traverse placental membrane Increased blood sugar in Fetus Fetal pancreatic b cell hyperplasia Increased insulin & pro insulin level

23. Continued……… Increased insulin & pro insulin level Glycogen deposition inhibits fetal lung protein synthesis maturational effect of fat deposition cortisol hepatic glucose production Macrosomia Hypoglycemia RDS Birth injury

24. How to diagnose??? History > h/o diabetes or Gdm in mother poor glucose control during pregnancy mother may have previous LGA infant Antenatal records> USG in last trimester_LGA baby

25. Clinical features Large baby Weak cry Lethargy, poor feeding Jaundice Plethoric with puffy face Blue or mottled skin color, Tachycardia,tachypnoe,respiratory distress Tremors shortly after birth Convulsions Hepatomegaly,cardiomegaly

26. Problems associated with IDM During birth Macrosomia Prenatal asphyxia Preterm labour Birth injury shoulder distocia,brachial plexus injury, fracture of clavicle or humerus. Still born

27. After birth problems associated with IDM LGA (contd.) SGA Hypoglycemia Hypocalcemia Hypomagnesaemia Respiratory distress syndrome Transient tachypnoe of new born Hyperbulirubinemea,hyperviscosity syndrome Congenital malformations vsd,asd,tga,anencephaly,meningocele,caudal regression syndrome, renal agenesis.

28. Long term Complications Obesity HTN DM Neurodevelopment deficit

29. Investigations s/glucose level at delivery,2,4,6,8,12,18,24,36,48,60,72 hrs of age. s/calcium level at 6,24,48 hrs of age s/magnesium level done if Hypocalcemia Hematocrit at birth 4 & 24 hrs of age s/bilirubin CBC,BBG

30. Chest x ray,x ray of joints in case of birth injury Echocardiogram Barium enema to rule out congenital anomalies

31. Management Continuing evaluation bsr monitoring, signs of hapocalcemea,jaundice,cvs disorders,rds,in 24 hrs Hypoglycemia 10% d/w infusion If persistent hypoglycemia consider a trial of corticosteroids & obtain endocrinology consultation Hypocalcemia with calcium gluconate Hypomagnesaemia with mgso 4

32. Management of other problems Treat accordingly

33. Prognosis Less morbidity & mortality with adequate control. Evidence suggests an increased incidence of obesity & metabolic syndrome during childhood. If diabetes is poorly controlled during pregnancy, a high risk of neurodevelopmental deficit is reported as child grows.

34. T h a n k y o u