Infants Diabetic Mothers

7/30/2019 Infants Diabetic Mothers

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Newborn Nursery Curriculum

Julee Waldrop, MS,PNP


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Diabetes in Pregnancy Diabetes in pregnancy 4%

Pre-gestational diabetes 12%

Gestational diabetes 88%


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Classification of Severity Whites Classification for diabetes

A Abnormal GTT treated with diet

A1 Medication controlled GDMA2 Insulin-treated GDM

B Onset at age >/=20 and duration of < 10 yr

C Onset at 10-19 years or duration > 10-19 years

D Onset before 10 yrs, duration > 20 yrs, somemacrovascular to microvascular disease

R-T Various complications have already occurred


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Pathophysiology Reduced insulin activity in the mom leads to a

hyperglycemic environment for the baby

In the first trimester this can cause embryopathy(birth defects and spontaneous abortions)

Highest risk are women with type 1 DM

In the 2nd & 3rdtrimesters can cause fetopathy

Macrosomia

Neonatal hypoglycemia


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Pathophysiology Intermittent maternal hyperglycemia leads to to

premature maturation of fetal pancreatic isletsand hypertrophy of the beta cells which producemore insulin causing hyperinsulinemia.

Hyperinsulinemia stimulates storage of glycogenin the liver, increased activity of hepatic enzymesin lipid synthesis and accumulation of fat inadipose tissue.

All this leads to increased fetal growth especiallyin insulin sensitive tissues, muscle and fat.


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Pathophysiology These increased metabolic needs require more O2

and leads to relative hypoxemia in the fetus

It also promotes catecholamine production which canlead to HTN and cardiac hypertrophy which may beinvolved in the 20-30% rate of stillbirth seen in poor

control


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Congenital Anomalies Type 1 DM RR was ~8 times greater

Account for about 50% of the perinatal deaths

Systems most frequently affected: CV and CNSAnencephaly and Spina bifida- 13-20 x more likely

DM during pregnancy accounts for most ofinfants born with caudal regression syndrome

(defects of the caudal region of the spinal cord) 200 x more likely

Spinal cord injury results in significant sequelae likeincontinence to paraplegia


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Prematurity Related consequences

Perinatal aspyxia can be related to many things Examples:

Maternal vascular compromise

Macrosomia

Prematurity


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Macrosomia Increased growth occurs after the 24th week of

pregnancy. There is a linear relationship between elevated blood

glucose and birth weight. Disproportionate growth

Excessive fat in the abdomen and scapular areas.

Increased risk for: Hyperbilirubinemia

Hypoglycemia

Acidosis


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Complications of Macrosomia Birth injury

Shoulder dystocia (1/3rd of infants > 4000gms)

1.7 times more likely to occur Brachial plexus injury

Clavicular or humoral fracture

Perinatal asphyxis

Facial palsy cephalohematomas


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IUGR If hypertension is significant enough with

vasculopathy then growth restriction may occur


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Respiratory Distress More common in IDMs when delivered prematurely

Delayed maturation of surfactant synthesis caused byhyperinsulinemia

TTNB 2-3 x more likely

Decreased fluid clearance in diabetic fetal lung

Cesarean delivery


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Metabolic Disorders Hypoglycemia

Definition: BGL < 40 mg/dL

Incidence: 14-21% Most common in macrosomic infants

Can also occur in IUGR

Persistent hyperinsulinemia in the newborn

Depressed counter response to hypoglycemia Glucagon

catecholamines


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Metabolic Disorders Hypocalcemia

Infrequent in term infants

Routine evaluation not recommended but maycontribute to persistent hypoglycemia

Hypomagnesemia

Infrequent in term infants

If hypocalcemia occurs is more likely


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Polycythemia Definition: HCT > 65%

Incidence: 13-33%

Fetal hypoxemia stimulates synthesis of erythropoietinwhich leads to polycythemia

Puts infants at risk for renal vein thrombosis (morecommon in IDMs)

Recommend measurement within 12 hours of birth


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Hyperbilirubinemia Incidence: 11-29%

Risk factors

Prematurity Polycythemia

Macrosomia


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Cardiomyopathy Hypertrophic cardiomyopathy

30-50% of IDMs

Increased thickening of the interventricular septum Hyperinsulinemia leads to increased deposition of

fat in myocardial cells

Symptomatic in only 15-20%

Resolves on its own as insulin levels decrease

Echo normalizes in 6-12 months

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Infants Diabetic Mothers