Infant of a Diabetic Mother - DOC by PyLL1m9Z

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									Infant of a Diabetic Mother

Frequency- 4% of pregnant woman have diabetes
      88% have gestational diabetes
      12 % known diabetics (35% type 1 and 65% type 2)

Pregnancy-risks
      -White criteria
      -Complications minimal with gestational diabetes vs. pregestational
      diabetes
      -Highest risk of birth defects in women with renal, cardiac or retinal disease
      -Complications of diabetic pregnancies cause poor prognosis i.e.
      Preeclampsia twice as common in diabetic pregnancies vs normal
      pregnancies

Fetal Effects- increased insulin activity creates a metabolically abnormal
environment
       6-7 th week- birth defects and spontaneous abortions
       2nd/3rd trimester- macrodome and neonatal hypoglycemia

Diabetic fetopathy- intermittent maternal hyperglycemia causes fetal
hyperglycemia, which leads to premature maturation of fetal pancreatic islets,
resulting in hyperinsulinemia in the fetus

This causes:
   1) macrosomia
   2) fetal hyperinsulinemia increases metabolic rate which leads to increased
       oxygen consumption and relative hypoxia in the fetus

fetal growth
-1st and 2nd trimester normal then in 3rd trimester larger abdominal girth and larger
organs, normal size head

fetal hypoxia
    1) stimulates erythropoietin which causes polycythemia
    2) promotes catecholamine production which leads to HTN and cardiac
        hypertrophy
    3) may contribute to 20-30% still birth rate in poorly controlled diabetics


Neonatal Effects (seen 0.6-4% of diabetic pregnancies)

Congenital Anomalies
     2/3 are cardiovascular or CNS
     anencephaly and spina bifida occur 12-20 more in IDMs than non-diabetic
mothers

       common cardiac anomalies- transposition, VSD, coarc, ASD

       GI, GU and skeletal anomalies are also seen- specific to IDM’s is small left
colon syndrome- inability to pass meconium that resolves spontaneously

Caudal Regression Syndrome- (caudal agenesis, sacral dysgenesis or caudal
dysplasia sequence) occurs 200 times more frequently in IDM than in regular
pregnancy. Spectrum of structural defects of the caudal region- incomplete
development of the sacrum and the lumbar vertebrae. Because of the
involvement of the distal spine- neurological impairment is involved- ranging from
incontinence to decreased growth and movement of the legs

Premature Delivery- spontaneous premature labor occurs more frequently

Perinatal Asphyxia- IDM are at higher risk for intrauterine or perinatal asphyxia
(low fetal hr, low apgars and intrauterine death)

Macrosomia- defined as >90% or >4000 grams. Typically appear large and
plethoric, with excess fat accumulation in abdominal and scapular regions, and
visceromegaly

       -predisposes to birth injury, shoulder dystocia, brachial plexus palsy,
clavicular and humeral fractures, perinatal asphyxia and cephalohematoma

IUGR- IDM can be IUGR if poorly controlled diabetic (class F)

RDS- more frequent in infants of diabetic mom’s
      -delayed maturation of surfactant synthesis caused by hyperinsulinemia

Other causes of Respiratory Distress-hypertrophic cardiomyopathy, and TTN

Metabolic complications

Hypoglycemia
     <40 mg/dl (27% of IDM have hypoglycemia)
     usually occurs in first few hours of life
     occurs because of persistent hyperinsulinemia

Hypocalcemia
     <7mg/dl
     usually occurs in 24-72 hour of life
      thought to be due to low PTH in infant which may be due to increased
maternal Ca during pregnancy

      usually asymptomatic and resolves on its own
      symptoms include- jitteriness, lethargy, apnea, tachypnea and seizures
      routine screen not recommended

Hypomagnesemia
     <1.5mg/dl
     occurs in 40% of IDM
     transient and asymptomatic
     may need to treat if hypocalcemic

Polycythemia and hyperviscosity
       Central crit>65
       Occurs in 13-33% of IDM
       Related to hypoxia inutero
       Hyperviscsity- may lead to sludging and ischemia and infaction of internal
organs

Hyperbilirubinemia
     11-29% in IDM
     thought to be due to increased hemolysis

Cardiomyopathy
       Most are asymptomatic, but 5-10% have respiratory distress or signs of
poor cardiac output or heart failure
       Usually transient but needs to be supported
       ECHO resolves in 6 months
       Thought to be due to fetal hyperinsulinemia, which increases synthesis and
fat deposition in myocardial cells

								
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