4. “Introduction”
•Approximately 6% of pregnancies are complicated by
maternal diabetes mellitus (80% of which are gestational).
•Maternal hyperglycaemia can result in fetal hyperglycaemia
and then secondary fetal hyperinsulinism.
•Insulin is the main 'growth hormone' of the fetus and therefore
infants of diabetic mothers (IDM) are often macrosomic (>
4,000 g) or large for gestational age (>90th percentile).
•The problems associated with being IDM relate to the effects of
hyperinsulinism and/or macrosomia
•The macrosomia is due to excessive fat deposition, visceral
organ hypertrophy (except brain and kidney) and acceleration
of body mass accretion.
•Macrosomic IDMs have higher rates of neonatal morbidity and
mortality.
5. “Definition”
An infant of a diabetic mother is a baby born to
a mother who has diabetes. The phrase
specifically refers to a baby who is born to a
mother who had persistently high blood sugar
(glucose) levels during pregnancy .
6. “Incidence”
•Insulin dependent diabetes occurs in 0.5% of
all pregnancies.
•In addition 1-3% of women shows biochemical
abnormalities during pregnancy consistent with
gestational diabetes.
7. “Pathophysiology”
abnormal fetal
developmental
physiology
increased flux
of glucose
from mother
to fetus
Hyperglycemia,
Hyperinsulinemia,
Increased metabolic rate,
hypoxemia
Redistribution of cardiac output,
Increased release of
norepinephrine, and blunted
release of glucagon.
•More fat is stored in
adipocytes
•More glycogen is
stored in the liver
•The heart may
develop asymmetric
septal hypertrophy.
•lung metabolism is
altered to delay the
appearance of mature
surfactant.
8. •At birth, the macrosomic IDM develops
hypoglycemia that has a multifactorial basis
(hyperinsulinemia, hypoglucagonemia, and probably
diminished gluconeogenic and cortisol production
rates).
• The IDM may experience respiratory symptoms
from one of three causes: IRDS, persistent pulmonary
hypertension, or congestive heart failure.
•Hyperbilirubinemia may occur because of increased
rate of hemolysis; hypocalcemia and
hypomagnesemia are likely within the first 3 days in
association with a sluggish PTH response; and
abnormal levels of inhibitors of fibrinolysis and
platelet prostaglandin E-like substances may
stimulate abnormal thrombosis.
9. “Risk Factors”
Fetal macrosomia posses health risk for mother and
baby both during pregnancy and after child birth.
•Maternal diabetes
•A history of fetal macrosomia
•Maternal obesity
•Excessive weight gain during pregnancy
•Previous pregnancies
•Gender of baby
•Overdue pregnancy
•Maternal age
10. “Fetal effects of maternal
hyperglycemia”
•Poor glycaemic control during embryogenesis can result in a 4 to 8
fold increase in congenital malformations, including
cardiac defects
CNS defects (including anencephaly and spina bifida)
genitourinary and limb defects
•Macrosomia leading to increased risk of
shoulder dystocia
clavicular fracture
brachial plexus injury
facial nerve injury
cephalhaematoma
asphyxia
perinatal and neonatal mortality
11. Continues….
•Episodic fetal hypoxia stimulated by episodic maternal
hyperglycaemia leads to an outpouring of adrenal
catecholamines, which can cause
Hypertension
Cardiac hypertrophy
Stimulation of erythropoietin, leading to
polycythaemia and therefore hyperviscosity
Increase risk of thrombosis
Hyperbilirubinaemia (increased red cell mass)
12. “Perinatal complications of
diabetes in pregnancy”
• Increased perinatal mortality due to
o congenital malformations
o extreme prematurity
o fetal demise
o growth restriction
o intrapartum asphyxia
o RDS
• Birth injury
o Shoulder dystocia
o Brachial plexus trauma
13. “Clinical Manifestation”
Large
Large and plump baby (macrosomia) with puffy facies.
Infant may also be of normal or low birth weight, particularly if they
are delivered before term or association with maternal disease.
Infant may be jumpy, tremulous & hyperexcitable during the 1st
3
days of life although hypotonia, lethargy and poor sucking also may
occur.
Hypoglycemia
Hypocalcemia
Sign of respiratory distress secondary to immature lungs can be
noted on examination.
Cardiac disease may be present.
Gross congenital anomalies may be noted on physical
examination
14. “Neonatal complications of diabetes
in pregnancy”
Macrosomia
Small for gestational age
Polycythaemia and hyperviscosity
Hypoglycaemia
incidence varies from 25-40% usually presents within
1-2 hours after delivery.
Hypocalcaemia is (up to 50%) serum Ca levels are
lowest at 24-72 hours of age.
Hypomagnesaemia
Birth asphyxia 25%
Birth trauma
16. “According to resent research conducted at peshawr in
july 2012”
42 consecutive cases of infants of Diabetic mothers were enrolled
in the study, all their maternal Hx esp obst Hx n complete neonatal
examination was done….
The Results of that study were
Out of 42 diabetic mothers, gestation diabetes was seen in 71.4%
while pre-conceptional diabetes was seen in 28.5%.
The male Infants of Diabetic Mothers in this study were 69%.
Infant of Diabetic Mothers delivered by C-section were 45%.
Macrosomia 40.4% was found to be the most common
complication followed b hypoglycaemia 23.8%.
The mortality rate in that study was 4.7%
17. “Investigations”
Serum glucose levels should be checked at delivery and at
½ , 1, 1 ½ . 2, 4, 8, 12, 24, 36 and 48 hours of age.
Serum calcium levels
The hematocrit should be checked at birth and at 4 n 24
hours of age.
Serum bilirubin levels should be checked as indicated by
physical examination.
ABGs, CBC, cultures are gram stains should be obtained
as clinically indicated.
Radiological studies are not necessary unless there is
evidence of cardiac, respiratory or skeletal problems
ECG and echocardiography should be performed if
hypertrophic cardiomyopathy or a cardiac malformation is
suspected
18. “Neonatal management and
treatment”
Upon delivery, the infant should be evaluated in the usual manner.
Blood glucose levels and the hematocrit should be obtained.
Observe for jitteriness, tremors, convulsions, apnea, weak cry and poor
sucking.
A physical examination should be performed paying special attention
to heart, kidneys, lungs n extremities.
For hypoglycaemia Infuse a bolus of 2 ml/kg of 10% glucose
solution at a rate of 1.0ml/min, then give a continuous infusion of 10%
glucose at a rate of 6-8 ml/kg/min and increase the rate as needed to
maintain a normal blood glucose (. 40-50mg/dl).
The level should be followed every 30-60 mints until stable.
The highest concentration of glucose that can be infused through a
peripheral line is 12.5%.
19. Management continues…..
Other complications e.g hypocalcemia,
RDS, Birth Asphyzia cardiomyopathy, hyper
bilirubinemia etc should be managed
accordingly.
Start feeding when baby is stable and is able
to suck, and has no apparent complications.
Encourage breast feeding.
20. “Prognosis”
The morbidity and mortality is decreased with adequate
control of diabetes during the diabetic pregnancy
The risk of subsequent diabetes in the infants of these
women is atleast 10 times greater than in the normal
population.
Physical development is normal, but oversized infants may be
presispoed to obesity in childhood that may extend into adult life.
21. “Prevention”
To prevent complications, the mother needs care
throughout her pregnancy. Controlling blood sugar and
getting diagnosed with gestational diabetes early can
prevent many of the problems that can occur with this
condition.
Lung maturity testing may help prevent breathing
complications due to immature lungs if the baby is being
delivered more than a week before the due date.
Carefully monitoring the infant in the first hours after birth
may prevent complications due to low blood sugar.
Monitoring and treatment in the first few days may prevent
complications due to high bilirubin levels.
22. “it might be difficult to prevent
MACROSOMIA, but we can
promote a healthy pregnancy”
