Prepared By: Dr. Shaju Edavana

Introduction

Pathophysiology

Epidemiology

Complications

Management

Diabetes - most common medical

complication of pregnancy

Still an increased risk of complications

Any abnormal intolerance that begins or is

first recognized during pregnancy using

glucose tolerance test

Using 100 mg glucose load

Two or more of the plasma glucose

concentration must be met for the diagnosis.

Insulin level inhibit the maturational effect of

control on the lungs (RDS)

Gestational age Pathophysiology

Before 9 weeks Malformation

Before 20 weeks fetal islet cells are incapable of responding

hyperglycemia leading to IUGR.

After 20 weeks Fetus responds to hyperglycemia with

pancreatic beta cell hyperplasia and insulin

levels.

Seen in 3-10 % of pregnancies

In Kuwait incidence of Diabetes is high

23 % of population are diabetic-

35% type 1 and 65% type 2

Major congenital malformations are found in

5-9 % of affected infants

Affected Group Mortality Rates

Still birth and perinatal 5 times more than general

population

Neonates 15 times

Infants 3 times

Fetal macrosomia

Fetal congenital malformation

Impaired fetal growth

Pulmonary disease

Metabolic and electrolyte abnormalities

Haematological problems

Cardiovascular abnormalities

Congenital malformations

Large for gestational age

Birth weight more than 90th percentile or

above 4000 gm

More likely to have hyperbilirubinemia,

hypogycemia and acidosis

Birth injury, shoulder dystocia

Brachial plexus palsy and Subdural

haemorrhage

Facial palsy

Impaired Fetal growth (associated with ‘Too

tight control’ )

Maternal vascular disease

is the common cause of

impaired fetal growth

Poor glycaemic control

Associated with high risk of UTI and

maternal preeclampsia

Increased number of Respiratory Distress

Syndrome

More incidence of TTN, PPHN and

pneumothorax

In contrast, Fetal lung maturation may occur

in diabetic pregnancies complicated by

vasculopathy

Blood glucose level less than 2.6 mmol/L

Caused by hyper insulinemia due to hyperplacia of Fetal pancreatic beta cells

Neonate develops hypoglycaemia - continuous supply of glucose is stopped after birth

Strict glycaemic control decreases but does not abolish the risk

Symptoms –• Jitteriness• Irritability • Poor feeding • Weak cry• Hypotonia• Seizure

Definition → total serum calcium < 1.8 mmol/L

or ionized calcium < 1 mmol/L

Caused by lower PTH level

Symptoms → jitteriness or seizures

Definition → serum magnesium concentration less than 0.75 mmol/L

Mechanism is increased urinary loss secondary to diabetes

Prematurity may be a contributing factor

Hypocalcaemia may not respond to treatment until the hypomagnesaemia is corrected.

65% of all IDMs demonstrate abnormalities of

iron metabolism at birth

Iron deficiency increases an infants risks for

neuro-developmental abnormalities

Haematocrit more than 65%

Plethoric appearance, sluggish capillary refill

or respiratory distress

Excess red blood cells precursors lead to

hyperbilirubinemia or thrombocytopenia.

Hypertrophic cardiomyopathy with intra ventricular hypertrophy may occur in 50% of IDM

Infants are often asymptomatic, but 5 to 10% have respiratory distress or sign of heart failure

Symptomatic infants typically recover after 2-3 weeks of supportive care

VSD

TGA

PDA

Caudal Regression Syndrome → structural defects of caudal region → 200 times more frequent

Severe form is known as Sirenomelia or Mermaid Syndrome

Risk of Spinabifida →20 times higher

Anencephaly → 13 times

Microcephaly, holoprosencephaly

Renal → hydronephrosis, renal agnesis,

ureteral duplication

GI → duodenal or anorectal atresia, Small

Left Colon Syndrome (presents as transient

inability to pass meconium, lower bowel

obstruction)

Unilateral micro-opthalmia

Bilateral Microtia

Cleft Palate

Micro Penis

Unilateral Cryptorchidism

Bilateral Radial Hypoplasia

Unilateral Polydactyly

Bifid Tongue

Single Umbilical Artery

Investigation

1. CBC

2. RBS

3. ABG

4. Calcium

5. Magnesium

6. Chest X-ray

7. Abdominal X-ray

8. Echo

9. Barium Enema

Periconception control

HbA1C – maintain 7% -tight glycemic control

and avoid pre-eclampsia

Intervention is required if:

1. plasma value < 36 mg/dL or 2 mmol/L

2. infant develop symptoms

3. glucose level does not increase after feeding

Target glucose level 45 mg/dL or 2.5 mmol/L

Profound hypoglycaemia requires IV therapy

with hydrocortisone

Immediate IV therapy with 2-4 ml/Kg in symptomatic infants

Maintain continuous infusion of 6-8 mg/Kg/min

If the follow-up glucose level remains low, dextrose infusion increase by 2 mg/kg/min

Maintain 80-100 ml/kg/day

If infant requires dextrose concentration more than 12.5% insert central line

Early breast feeding- colustrum as well as

breast milk provides generous concentration

of glucose

Monitor plasma glucose routinely

Adequate enteral feeding

Cardiologic screening

Excellent prognosis