This document discusses infants of diabetic mothers and post-term infants. It provides information on: 1. Infants of diabetic mothers can experience altered physiology in utero like hyperinsulinemia which can lead to issues like hypoglycemia, hypocalcemia, birth trauma, and respiratory problems. Close monitoring is needed for these infants. 2. Post-term infants, defined as those born after 42 weeks gestation, are at higher risk for problems due to placental aging like fetal distress, meconium aspiration, hypoglycemia, and hypothermia. Care involves monitoring, maintaining warmth and blood sugar levels, and watching for complications. 3. The management of infants of diabetic mothers and

1. Presenter :- Ms. Shilpa joshi
Post-term infant, infant of diabetic mother

2. • POST TERM NEONATE :-
• The normal length of pregnancy is from 37 weeks to 42 weeks
• Prolonged pregnancy is also referred to as post term, post
maturity and postdates pregnancy and is said to be the one
that exceeds 42 weeks of gestation
• Prolonged pregnancy and post term are used synonymously
and relate to the duration of pregnancy and not a maternal
condition ( Fraser et.al, 2006).The most frequent cause of post
term pregnancy is inaccurate dating.
• Prolonged pregnancy is the most common reason for
induction of labour.
• The post newborn is at high risk for morbidity and has a
mortality rate two to three times greater than that of term
infants.

4. • Prolonged pregnancy; Defined as a pregnancy that exceeds
42 weeks gestation or 294 days past the first day of the
mothers last normal menstrual period (Marcia et al, 2007).
• Post term; Any newborn born after 42 weeks of gestation
(Joel et al, 2007).
• Incidence:- 12% of all births.
• CAUSES
• The cause of prolonged pregnancy is unknown.

5. • RISK FACTORS
• • Miscalculation or inaccurate last menstrual period.
• • Lack of stimulation factors such as oxytocin and
prostaglandins e.g. in women who take high doses of aspirin
or like compounds, which are known to inhibit the synthesis
of prostaglandins.
• Prime gravidae
• High parity ( five or more pregnancies)_ the recurrence risk of
post term birth increases with parity.
• Previous post term pregnancy
• Advanced maternal age is a strong risk factor (over 35 years)

6. • DIAGNOSIS
• The accurate diagnosis of postdates pregnancy can be made
on by proper dating.
• The estimated date of delivery is most accurately determined
early in pregnancy. However, the following aid in diagnosis.
• History taking
• Establish the first day of the last normal menstrual period.
Then calculate the expected date of delivery. For the EDD to
be accurate: The woman should be sure of her LMP
• • The period must have been of normal length and regular.
• • Not having been on oral contraceptives pill.
• • Quickening; maternal perception of first fetal movements
at about 16-20 weeks.

7. • Abdominal examination
• • On abdominal inspection the pregnancy appears bigger than
the gestational age.
• • Abdominal palpation for height of fundus which will be
more than 40 weeks.
• Ultra sound scanning
• • In patients without reliable clinical data, ultrasound is
beneficial. However, ultrasonography is most accurate in early
gestation (before 12weeks).
• After 12weeks,the crown-rump length becomes less accurate in
determining gestational age because the fetus begins to curve.
• • Ultra sound can also show placental calcification and the
amount of amniotic fluid at term which is reduced in postterm.

8. • RISKS AND CLINICAL IMPLICATIONS OF POST-TERM PREGNANCY.
• FETAL RISKS
• • AT the end of pregnancy, the placenta which supplies the fetus
with oxygen, nutrients and removal of wastes begins to fail to
function properly due to aging or infarction.
• Therefore, the baby’s health may be at risk of :-
• Asphyxia
• respiratory distress syndrome and
• meconium aspiration. In addition, the following occurs;
• Fetal distress syndrome due to insufficient oxygen supply to the
fetus
• • Oligohydraminious occurs due to reduced urine output by the
fetus
• • Hypoglyceamia due to too little glucose producing in stores.

9. • Clinical manifestation :-
• Wasted physical appearance
• Little subcutaneous fat
• Long thin appearance
• Long finger and toenails
• Minimum vernix caseosa
• Abundant scalp hair
• Skin frequently cracked and desquamating parchment paper
like pale skin
• Absence of lanugo hair

10. • Diagnostic evalution :-
• General appearance
• Gestational age
• APGAR score
• Blood gases

11. • PROBLEMS ASSOCIATED WITH POST MATURITY
• FETAL DISTRESS :- The effect of uterine contractions on an already
compromised placenta may cause fetal hypoxia causing the fetus
to be distressed.
• MECONIUM ASPIRATION.
• • Hypoxia and distress may cause relaxation of the anal
sphincter leading to the passage of meconium while in utero.
• • The fetus can aspirate the meconium stained liquor into
the lungs either in utero or during delivery.
• HYPOGLYCEAMIA
• • May result from nutritional deprivation and resultant
depleted glycogen stores.
• HYPOTHERMIA
• • This is due to decreased liver glycogen and brown fat stores.
• • This is due to reduced fats which act as an insulator.

12. • POLYCYTHEMIA
• • This is the increase in the red blood cell production coming
in as a result of hypoxia.
• BIRTH INJURIES
• • There will complete ossification of the skull bones leading
to poor moulding which contributes to birth injuries.
• SEIZURES
• • The neonate can have episodes of seizures which can come
as a result of the hypoxia experienced during intra uterine
• INTRA UTERINE DEATH
• • This can result from acute fetal hypoxia while it is in uterus
and this can lead to fetal death

13. • MANAGEMENT OF A POST MATURE BABY
• • The management is directed at differentiating the fetus
that has post maturity syndrome from the one who is large,
well nourished and tolerated the prolonged pregnancy.
• • The goal of management is to identify and manage the
post mature newborn’s potential problems.
• PSYCHOLOGICAL SUPPORT
• • Provide emotional support to the parents to encourage
them as the neonate may appear with dry cracking skin and
possible aspiration of meconium.
• • Explain all the procedures in order to obtain co- operation.
• MAINTAINING A CLEAR AND PATENT AIR WAY
• • If the amniotic fluid is meconium stained the baby’s nose
and mouth should be wiped before the baby takes its first
breath to minimize the chances of meconium aspiration
syndrome . After birth the direct suctioning of the trachea is
needed.

14. • OBSERVATION
• • Observe the cardiopulmonary function of the neonate
because of the stress of labour which is poorly tolerated by the
post mature infant and may lead to severe birth asphyxia.
• • Monitor the apical beat of the neonate which should be in the
range of 120b/m to 160b/m as well as the respirations which
should be between 30 to 60 b/m.
• • Monitor the skin colour as these neonates tend to be
cyanosed as well as jaundiced.
• • There is also need to observe for the occurrence of
convulsions which are likely to be experienced by the neonate.
• • Observe for any injury the neonate can sustain such cephalo
heamatoma and caput succedenum.
• • Other observations are as for any normal neonate.

15. • OBSERVATION
• • Observe the cardiopulmonary function of the neonate
because of the stress of labour which is poorly tolerated by the
post mature infant and may lead to severe birth asphyxia.
• • Monitor the apical beat of the neonate which should be in
the range of 120b/m to 160b/m as well as the respirations which
should be between 30 to 60 b/m.
• • Monitor the skin colour as these neonates tend to be
cyanosed as well as jaundiced.
• • There is also need to observe for the occurrence of
convulsions which are likely to be experienced by the neonate.
• • Observe for any injury the neonate can sustain such cephalo
heamatoma and caput succedenum.
• • Other observations are as for any normal neonate.

16. • PROVISION OF WARMTH
• • The post mature neonate tends to suffer from hypothermia
because of their reduced fat stores.
• • The neonate can be nursed together with the mother through
skin to skin contact hence provision of warmth from the mother
more especially if the condition is stable.
• • If the condition of the neonate needs interventions from
neonatal intensive care unit then the neonate can be nursed in the
pre warmed incubator with an incubator temperature of (32.5 to
37.7 degrees Celsius).
• • The environment should be warm enough to provide
enough heat to the neonate as this baby has low glycogen and
brown fat stores

17. • PREVENTION OF HYPOGLYCAEMIA
• • If the neonate is unable to suck. Intravenous fluid of 10 % of
dextrose can be given.
• • This can be followed by breast feeding either
expressed or cup and spoon type of feeding until such a time a
baby can breast feed on its own.
• • Early initiation of feeding is very important to prevent
hypoglycaemia (within 1 hour) after delivery.
• • Frequent monitoring of blood glucose is very cardinal
to ensure that the neonate is not in a state of hypoglycaemia.

19. 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:

20. 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.

21. 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.

22. Diabetes Mellitus
A chronic metabolic disorder involving
complete or decreased insulin secretion
or other insulin dysfunction resulting in
increased serum glucose concentration.

23. 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

24. 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

25. Morbidities in Infants of Diabetic Mothers
• Macrosomia
• Hypoglycemia
• RDS
• IUGR
• Hypocalcemia
• Hyperbilirubinemia
• Congenital Anomalies
• Polycythemia
• Hyper viscosity
• Cardiomyopathy
• Increased fetal death
• Postnatal problems

26. 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.

27. 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.

28. 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.

29. 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.

30. Congenital Anomalies
• Many reported.
• Most common are CV, Musculo-Skeletal &
CNS.
• Incidence decreased with tight glucose control
in mothers.

31. 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

32. 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.

33. 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

34. Polycythemia/ Hyperbilirubinemia
• Fetal hypoxiaPolycythemia hyperbilirubinemia
• ? Ineffective RBC Production
• Polycythemia may lower glucose levels

35. Management of IDMs
• Delivery:
Consider as high risk. (mother & infant)
Follow basic steps of resuscitation for infant.

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

37. • Nursing Management
• 1. Establish an initial database.
• Review the mother’s health history and
history of the pregnancy.
• Complete an initial newborn examination and
assess for birth injuries.

38. • 2. Monitor for complications.
• Monitor for signs and symptoms of hypoglycemia Measure
the newborn’s glucose level according to nursery protocol.
• Feed the newborn early according to nursery protocol to
prevent or treat hypoglycemia.
• If signs and symptoms continue after feeding, observe for
other complications.
• Monitor for signs of hypocalcemia Obtain hematocrit value;
report the findings to the physician.
• Observe for signs of respiratory distress (e.g., nasal flaring,
grunting, retractions, and tachypnea).
• Initiate gavage feeding if the newborn cannot suck well or if
the respiratory rate exceeds normal (30 to 60 breaths per
minute).

39. Management of Hypoglycemia
• May be asymptomatic
• Can occur within 30 minutes.
• May last up to 48 hrs or more.
• Early feeds. Blood glucose evaluation at 30 and 60 minutes
and at 2,4,6, and 12 hours after birth as directed by nursery
protocol
• If results are abnormal, repeat testing every 30 to 60
minutes until newborn achieves stable level; also test
before each feeding for 24 hours.
• Blood Glucose < 45 mg/dl IV dextrose recommended.

40. 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.

41. 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

42. • Research study :-
• Infants of diabetic mothers. A cohort study
• June 2014Saudi Medical Journal 35(6):572-7
• SourcePubMed
• Authors:
• Abeer E Lasheen et all
• Security Forces Hospital Programme
• Abstract and Figures
• Objective: To determine the outcome of infants born to diabetic mothers at Security Forces Hospital,
Riyadh, Saudi Arabia, and compare the complications seen in these infants with infants of non-diabetic
mothers. Methods: This is a concurrent prospective cohort study of a population of newborn infants
delivered at Security Forces Hospital, Riyadh, Saudi Arabia for diabetic mothers between January 2011
and November 2011. Results: A total of 601 infants were enrolled in the study consisting of 319 infants
of non-diabetic mothers, and 282 infants of diabetic mothers. Infants of diabetic mothers showed
significantly higher rates of associated complications and prolonged hospital stay reflected in their
admission to the neonatal intensive care when compared with infants of non-diabetic mothers. There
was no difference in rate of complications between infants of gestational diabetics and pre-gestational
diabetics. Conclusion: Our study showed that diabetic pregnancies are associated with an increased
incidence of neonatal complications. These seem to be related to the degree of maternal glycemic
control. The higher rates of complications among our infants of diabetic mothers, particularly major
congenital malformations call for those involved in the care of diabetic mothers to consolidate their
efforts to facilitate early booking in specialist clinics.

43. • Bibliography :-
• 1.Ghai,”Essential of pediatrics”(2010), 7th edition, CBS
publishers & Distributors (p) ltd. New Delhi. page no. 257-58
• 2.Gupte Suraj, “The short Text Book of Pediatrics”,(2009), 11th
edition, Jaypee Brothers Medical Publishers New Delhi. page
no. 570-71
• 3. Marlow R. Dorothy &Barbara A. Redding (2005),”Text Book
Of Pediatrics Nursing”,6thEdition,Saunders, An Imprint Of
Elsevier, Philaddelphia. Page no. 606-613
• 4.Wong’s ; “essentials of pediatric nursing”, 8th edition; Noida:
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• 5.www.medline.co.in