1. Infant of a Diabetic Mother Review of Newborn Implications Jamie Haushalter, CPNP-PC Newborn Nursery Emily Freeman, CPNP-PC Newborn Nursery Erin Burnette, NP-C Newborn Nursery

2. Purpose and Objectives Review pathophysiology of diabetes in pregnancy and implications for the newborn Apply “Up to Date” Information to practice. The learner will be able to Identify at least 3 neonatal complications associated with being an infant of a diabetic mother. Explain the pathophysiology of increased incidence of respiratory distress in the IDM infant.

3. Types of Diabetes Preconception Diabetes Type 1 or Type II Diabetes 1.8 percent prevalence Usually diagnosed if fasting glucose ≥92 or random glucose ≥200. Hgb A1C ≥6.5% Gestational Diabetes Diabetes first diagnosed during pregnancy. 2-25% prevalence Glucose tolerance test btw 24- 28wks 1hr (50g): ≥130 with 99% sensitivity and 77% specificity 1hr (50g): ≥140 with 85% sensitivity and 86% specificity

4. Gestational Diabetes: Classifications The White Classification system is used to differentiate between gestational diabetes and diabetes that existed prior to pregnancy. Gestational diabetes is class A with the following subclassifications: A1GDM: diet controlled A2GDM: medication controlled with insulin versus oral anti-hyperglycemic agents Insulin is recommended therapy, as oral anti-hyperglycemics are not approved for treatment of GDM, however they are often used. Oral anti-hyperglycemic agents that are sometimes used: Glyburide: studies have not shown an increased risk of excessive neonatal hypoglycemia with this medication. Metformin: Often provides less control of maternal blood sugars than insulin or glyburide.

5. Maternal Diabetes Results in Fetal Complications….WHY? In first trimester, hyperglycemia can lead to SAB or birth defects, more commonly in pregestational diabetes. In the 2 nd and 3 rd trimesters, diabetic ‘fetopathy’ begins to occur. Higher levels of glucose and insulin in the mother causes fetal hyperglycemia, hyperinsulinemia, and macrosomia which can lead to neonatal complications. Greater risk of birth injuries: shoulder dystocia, clavicle fracture, brachial plexus injury, cephalohematoma, asphyxia

6. Neonatal Complications Congenital anomalies Prematurity Perinatal asphyxia Macrosomia Respiratory distress Metabolic abnormalities Polycythemia Low iron stores Hyperbilirubinemia Cardiomyopathy

7. “Fetopathy” Chronic fetal hyperinsulinemia Caused by increased metabolic demands O2 consumption, fetal hypoxemia, erythropoiesis Caused by placental insufficiency Polycythemia- ?HTN and cardiac hypertrophy Fetal Complication- still birth

8. Neonatal Complications Congenital Anomalies Heart malformations are present in 3- 9% of diabetic pregnancies Most common heart defects seen in infants of diabetic mothers: Transposition of the great arteries Double outlet right ventricle Ventricular septal defect Truncus arteriosus Tricuspid atresia Patent ductus arteriosus Neural tube defects, intestinal complications, and orthopedic anomalies also more common. Risk of anomalies reduced by tight maternal glycemic control Prematurity Due to both medically indicated and spontaneous deliveries. Women with diabetes are more at risk for delivering early, however mechanism is unclear. May be related to preeclampsia, developing macrocomia, nephropathy, poor glycemia control, and risk of late fetal death.

9. Neonatal Complications Perinatal Asphyxia Increased metabolic rate, leading to increased oxygen consumption and fetal hypoxemia, as placenta cannot keep up with demands. Macrocomia can make delivery difficult, increased risk of shoulder dystocia. Cardiomyopathy leading to abnormalities in fetal heart rate. Macrosomia Maternal elevated sugars cause increased growth of the fetus, especially in insulin sensitive tissues (SQ fat, cardiac muscle, liver). Elevated insulin levels in the fetus stimulates glycogen storage in the liver, increased lipid synthesis, and accumulation of fat. Infants have bigger head:chest and shoulder:head ratios, more body fat, and visceromegaly. Disproportionate macrosomia increases the risk of hyperbilirubinemia, hypoglycemia, metabolic acidosis, and respiratory distress.

10. Neonatal Complications Respiratory Distress Common complication in infants born to diabetic mothers because maternal hyperglycemia delays surfactant synthesis and can lead to impaired or delayed lung maturation. Increased risk of neonatal respiratory distress syndrome 2-3 times more likely to have Transient Tachypnea of the Newborn (TTN) Hypothesized to be caused by delayed fluid clearance in the diabetic fetal lung C-sections more common in this population which also increases risk of TTN Metabolic Abnormalities Hypoglycemia Defined as BG <40, onset usually within the first few hours of birth Commonly occurs in macrosomic infants because of continued hyperinsulinemia even after being removed from their intrauterine glucose supply, even 2-4 days. Strict maternal glucose control can reduce the risk but does not eliminate the possibility of hypoglycemia in the newborn. SGA infants also at risk because of decreased glycogen stores and hyperinsulinemia decreases the ability to mobilize hepatic glycogen.

11. Neonatal Complications: Metabolic Abnormalities Hypocalcemia Serum Ca <7mg/dL Occurs in 5-30% in IDMs Good maternal glycemic control reduces risk Infants usually asymptomatic and resolves without treatment, therefore routine screening not recommended. Consider measuring in symptomatic infants: jittery, apnea, tachypnea, lethargy, seizures. Hypomagnesemia Serum Mg level <1.5/dL 40% of IDMs within the first 3 days after birth. Thought to be due to low maternal levels from urinary loss secondary to diabetes. Usually transient and asymptomatic therefore no need to screen unless clinical concern.

12. Neonatal Complications Polycythemia Increased erythropoietin concentrations caused by chronic fetal hypoxemia Polycythemia can lead to hyperviscosity syndrome and vascular sludging (if severe can cause ischemia and infarction or organs) Check hematocrit within 12 hours of birth One study showed 17% on IDMs had Hcts> 60 and 5% >65 Low iron stores Inversely related to degree of polycythemia. With hypoxemia, fetus has increased red cell mass, which causes iron redistribution, leading to iron deficiency in developing fetal organs  cardiomyopathy, neurodevelopmental problems, etc. As extra red cells are eventually broken down, the iron will be recirculated, so supplementation is not necessary.

13. Neonatal Complications Hyperbilirubinemia 11-29% of IDMs Associated with prematurity, poor maternal glycemic control, macrosomia and polycythemia Cardiomyopathy Increased risk of transient cardiomyopathy thought to be caused by fetal hyperinsulinemia increasing the synthesis and deposition of fat and glycogen in myocardial cells. Decreases size of ventricles, possibly obstructing outflow of the left ventricle. Infants with cardiomyopathy are often asymptomatic, however 5-10% will have respiratory distress or signs of poor cardiac output. Congestive cardiomyopathy rare.

14. Management of the Infant of a Diabetic Mother Lab testing for hypoglycemia and polycythemia. Glucose monitoring within 1-2 hours after birth and with symptoms. Should be preprandial and continue for the first 12-24 hours of life. Check hematocrit 12 hours after birth. Assess for cardiac and respiratory disease if cyanosis present. Monitor for jaundice If symptomatic, consider calcium and magnesium levels.

15. Outcomes Genetic susceptibility for development of diabetes, especially if mother has type 1. 2% risk if mom has type 1 diabetes versus 0.4% if mother did not have diabetes. With type 2 diabetes, a first degree relative has a 5-10x higher chance of developing T2DM. Risk for increased BMI, obesity, and impaired glucose metabolism due to intrauterine exposure to hyperglycemia and fetal hyperinsulinemia. If maternal diabetes is poorly controlled, risk of developmental abnormalities in the infant, especially if head circumference was small or if mother had higher ketone levels in the 2 nd and 3 rd trimesters.

16. Thank you for caring for our “cupcake” babies!

17. References http://www.uptodate.com/contents/infant-of-a- diabetic-mother http://www.uptodate.com/contents/screening- and-diagnosis-of-diabetes-mellitus-during- pregnancy?source=see_link http://www.uptodate.com/contents/infant-of-a- diabetic-mother http://www.uptodate.com/contents/screening- and-diagnosis-of-diabetes-mellitus-during- pregnancy?source=see_link Thank you!