Infant of diabetic mother

1. INFANT OF DIABETIC
MOTHER

2. INTRODUCTION
• Diabetes is the most common metabolic disorder to affect pregnancy.
• Associated with increased maternal morbidity as well increased risk
of fetal, neonatal, and long-term complications in the offspring.
• The outcome is generally related to the onset and duration of glucose
intolerance during pregnancy and severity of the mother's diabetes.

3. EPIDEMIOLOGY
• The International Diabetes Federation estimated that 223 million women
worldwide had DM in 2019.
• The Federation predicts that, this number will rise to 343 million by 2045
(both T1DM and T2DM).
• In developed countries, it is estimated that T2DM makes up 85% to 95% of
all cases of DM.
• Approximately half of women with a history of GDM go on to develop type
2 diabetes within five to ten years after delivery.

4. CLASSIFICATION OF DIABETES IN PREGNANCY
• Maternal diabetes ----
• Pregestational
• Gestational
• (T1DM , T2DM , Monogenic-MODY )

6. • Type 1 diabetes is characterized by insulin deficiency resulting from
autoimmune destruction of pancreatic insulin-producing beta cells
• Type 2 diabetes is characterized by insulin resistance and is therefore
more significantly associated with obesity.
• MODY - affecting beta-cell development, function, or regulation.

7. MODY
• AD inheritance , most commonly affected genes are glucokinase
(GCK) and hepatocyte nuclear factor (HNF1A, HNF4A).
• Women with GCK mutations usually have a stable, mild
hyperglycemia with elevated fasting glucose levels most prominent.
• HNF mutations represent the most common cause of monogenic
diabetes
• Treatment (HNF1A, HNF4A) – more responsive to sulfonylureas (e.g.,
glyburide) than to biguanides (metformin).

8. GESTATIONAL DIABETES
• Incidence of Diabetes in pregnancy is 6-7% , 85-90% are GDM.
• Definition - Carbohydrate intolerance of variable severity , resulting
from insulin resistance arising for the first time during pregnancy.
• Increasing rates of GDM are due to - increasing rates of obesity ,
older maternal ages at delivery,
physical inactivity, smoking, and
diets high in saturated fats

9. • GDM represents – maternal system failing to adapt to normal
pregnancy physiology .
• In early gestation --- Maternal fat stores
FFA concentration
As the gestation advances – insulin sensitivity decreases in liver and
peripheral tissues .

10. PATHOPHYSIOLOGY
Increase the glucose levels
To maintain steady supply of nutrients to the growing fetus.
Antagonize the effects of insulin at the cellular level
Decreases gastrointestinal motility, which may enhance carbohydrate absorption
Increases insulin resistance
Human Placental Lactogen, Progesterone, Cortisol, TNF A and Prolactin
In GDM , inadequate Insulin Secretion hyperglycemia in pregnancy
Usually diagnosed b/w – 24-28 weeks of GA .

11. IMPACT OF DIABETES IN PREGNANCY ON THE NEONATE DEPENDS ON :
• Time of onset of DM
• Degree of maternal hyperglycemia/hyperinsulinemia
• Length of fetal exposure to hyperglycemia (GDM resulting in a shorter
exposure than pregestational DM)
• Severity of maternal disease, because comorbidities (cardiac and
renal) have significant neonatal and obstetric effects

12. DIABETIC EMBRYOPATHY
• In women with pregestational diabetes, poor periconceptional glycemic
control has increased risk of embryopathy .
• The reported incidence of major congenital anomalies is approximately
threefold higher at 6%–12%. in DM( Cardiac – 40-50 % > CNS > SKELETAL )
• Leading cause of perinatal mortality
• No anomaly that is pathognomic to maternal DM .
• Sacral agenesis or caudal dysplasia should prompt evaluation for maternal
DM .

15. DIABETIC FETOPATHY - FETAL GROWTH & MACROSOMIA
• Poor glycemic control in pregnant diabetic women leads to
deleterious fetal effects throughout pregnancy.(2nd &3rd trimester )
• Fetal hyperglycemia, hyperinsulinemia and macrosomia , neonatal
hypoglycaemia

17. Chronic fetal hyperinsulinemia
elevated metabolic rates
increased oxygen consumption
placenta - unable to meet the
increased metabolic demands
FETAL HYPOXEMIA
increased mortality,
metabolic acidosis,
alterations in fetal iron distribution, and
increased erythropoiesis ,
POLYCYTHEMIA
OXIDATIVE STRESS
abnormal cardiac remodeling
hypertrophic cardiomyopathy
storage of glycogen in the liver
, increased hepatic enzymes activity involved in
lipid synthesis
accumulation of fat in adipose tissue.
long-term metabolic complications

18. NEONATAL
COMPLICATIONS
Macrosomia, which increases the risk of birth injury (eg, brachial
plexus injury)
Prematurity
Perinatal asphyxia
Cardiomyopathy
Respiratory distress
Metabolic complications including hypoglycemia and
hypocalcemia
Hematologic complications including polycythemia and
hyperviscosity , Low iron stores , Hyperbilirubinemia.

19. Macrosomia
• ACOG Defines macrosomia as Birth weight larger
than 4000 to 4500 grams (or 9 to 10 pounds).
• Shoulder dystocia represents an obstetric
emergency because of the risk of hypoxia,
hypoperfusion, and birth injury.
• Brachial plexus injury is the most common,
followed by clavicle or humerus fracture and
cephalhematoma.

20. COMPLICATIONS ASSOCIATED WITH MACROSOMIA
• Maternal : Protracted or arrested labor
Assisted vaginal birth
Cesarean birth
Genital tract lacerations
Postpartum hemorrhage
Uterine rupture
• FETAL : Shoulder dystocia leading to
birth trauma (brachial plexus injury,
fracture) or asphyxia.
• Neonatal -- Hypoglycemia ,
Respiratory problems ,
Polycythemia , Minor congenital
anomalies , Increased frequency
of admission and prolonged
admission to a neonatal
intensive care unit
• Childhood -- Obesity , Metabolic
syndrome , cardiac remodelling

23. SYNDROMES
ASSOCIATED
WITH
MACROSOMIA
Pallister-Killian
Beckwith-Wiedemann
Sotos
Perlman
Simpson-Golabi-Behmel
Costello
Weaver
Macrocephaly-cutis marmorata telangiectasia
congenita (M-CMTC)

25. Fetal Growth Restriction
• Women with T1DM or long-standing T2DM complicated by vascular
disease or renal disease are at high risk for fetal growth restriction
(asymmetrical FGR) .
• Diabetic ketoacidosis (DKA), maternal hypertension, pre- eclampsia,
and structural anomalies, all of which are more common in women
with T1DM and T2DM--- at risk for FGR

26. PERINATAL ASPHYXIA
• Intrauterine or perinatal asphyxia in IDM is due to macrosomia
(failure to progress and shoulder dystocia) and cardiomyopathy.
• Maternal vascular disease, manifested by nephropathy, may
contribute to the development of fetal hypoxia and subsequent
perinatal asphyxia.

27. Respiratory Distress
• RDS due to surfactant deficiency --
- Infants of mothers with diabetes are more likely to be delivered
prematurely
- maternal hyperglycemia appears to delay surfactant synthesis.
- Neonatal hyperinsulinemia, which interferes with the induction of
lung maturation by glucocorticoids.
• TTN occurs two to three times more commonly in infants of mothers
with diabetes than in normal infants

28. • ASSESSMENT OF FETAL LUNG MATURITY – By amniocentesis .

29. METABOLIC COMPLICATIONS :
• HYPOGLYCEMIA — Hypoglycemia, defined as blood glucose levels
below 40 mg/dL (2.2 mmol/L) in the first 24 hours of life .
• Hypoglycemia is likely caused by persistent hyperinsulinemia in the
newborn after interruption of the intrauterine glucose supply from
the mother.
• IDM s with neonatal hypoglycemia have elevated cord blood C-
PEPTIDE and S.INSULIN levels at birth .

30. • Strict glycemic control during last trimester and intrapartum
decreases, but does not abolish, the risk of neonatal hypoglycaemia
• ACOG – recommends maintaining maternal glucose levels between
70 &110 mg/dL.
• Postpartum management – early initiation of breast feeding ,prevents
hypoglycemia .

31. • HYPOCALCEMIA : S.Ca – 7 mg/dL , i.Ca - <4.4 mg/dL
• Mostly asymptomatic , resolves spontaneously .
• Result from a delayed transition from fetal to neonatal parathyroid
action in calcium metabolism as fetal parathyroid glands are relatively
inactive until after delivery .
• Risk increases with hypoxia, and preterm birth .

32. • HYPOMAGNESEMIA S.Mg < 1.5 mg/dL.
• Relevant in the context of significant hypocalcemia , as concurrent
hypomagnesemia makes the treatment of hypocalcemia more
difficult.
• Some hypothesize that - fetal hypomagnesemia may result from
lower maternal magnesium levels with diabetes from increased
maternal urinary losses or renal dysfunction

33. HYPERTROPHIC CARDIOMYOPATHY
• The prominent change is thickening of the interventricular septum
(IVS) with reduction in the size of the ventricular chambers, resulting
in potential obstruction of left ventricular outflow.
• Outflow obstruction occasionally is aggravated by anterior systolic
motion of the mitral valve.
• Cardiomyopathy is transient and resolves as plasma insulin
concentrations normalize.
• Symptomatic infants typically recover after 2-3 weeks of supportive
care, and echocardiographic findings resolve within 6 to 12 months

34. • Prenatal echocardiographic measurements (at 35 weeks or more)
• IVS thickness ≥4.5 mm
• IVS/left myocardial wall thickness (LMWT) ratio ≤1.18
• Predictive of hypertrophic cardiomyopathy & increased risk for
intrauterine and perinatal mortality

35. POLYCYTHEMIA
• Due to increased erythropoietin concentrations caused by chronic
fetal hypoxemia
• Polycythemia may lead to hyperviscosity syndrome, including vascular
sludging, ischemia, and infarction of vital organs.
• Hyperviscosity is thought to contribute to the increased incidence of
renal vein thrombosis

36. HYPERBILIRUBINEMIA
• Hyperbilirubinemia occurs in 25% of infants of mothers with diabetes,
especially in preterm & macrosomic infants .
• RISK – due to polycythemia (larger source of bilirubin to be conjugated
by the liver prior to excretion),
- ineffective erythropoiesis with an increased red blood cell
turnover
- to immaturity of hepatic bilirubin conjugation and excretion.

37. STILL BIRTH
• Before the use of insulin -(IUFD) or stillbirth occurred in up to 30% .
• Chronic intrauterine hypoxia – main cause .
• Greatest risk is among women with vascular disease, hypoglycemia,
DKA, macrosomia, polyhydramnios, and preeclampsia.

38. BREASTFEEDING
• Intrauterine exposure to maternal diabetes and/or obesity appears to
be associated with an increased risk of childhood obesity; successful
breastfeeding of durations greater than or equal to 6 months may
mitigate some of this risk.
• During lactation, women with diabetes have a significant decrease in
insulin or oral hypoglycemic medication requirements

39. LONG TERM OUTCOMES
• Increases the risk of postnatal metabolic complications (eg, diabetes,
increased body mass index [BMI], and impaired glucose metabolism)
and may also negatively impact neurodevelopmental outcome.

40. MATERNAL MONITORING TO LIMIT NEONATAL EFFECTS
• Antenatal Care - should ideally begin before pregnancy.
• Given the elevated risk of neural tube defects in diabetic pregnancies,
folic acid supplementation should be initiated before conception.
The US Preventive Services Task Force has recommended the use of
low-dose aspirin in women at elevated risk of developing preeclampsia
including women with pregestational diabetes (type 1 or type 2) .

41. SCREENING
• Women with risk factors for GDM should undergo early glucose
screening around 16 weeks’ gestation .
• All other women undergo universal GDM screening at 24 to 28 weeks
of gestation.
• ACOG - Two step” method consisting of a 50-g, 1-hour glucose
challenge test (GCT) and a 100-g, 3-hour oral glucose tolerance test
(OGTT) for a definitive diagnosis

42. • The International Association of Diabetes in Pregnancy Study Group
recommended in 2007 a simplified “one step” - 75-g, 2-hour glucose
tolerance test.
• Fetal Surveillance - assessment of fetal well-being and growth as well
as screening for congenital anomalies, is recommended.

43. Diagnostic Glucose Values for Gestational Diabetes
Treatment Targets for Gestational Diabetes Mellitus

44. The results of this trial point to a linear correlation between increasing maternal glucose
levels and increasing birth weight, primary cesarean delivery, fetal C-peptide levels, and
neonatal hypoglycemia.

46. PHARMACOTHERAPY
• Good glycemic control is a primary goal of the management of diabetes in
pregnancy.
• First-line therapy for women with gestational diabetes is nutritional and
lifestyle modification .
• Pharmacotherapy is indicated when nutritional control is inadequate.
• Both the American Diabetes Association and ACOG recommend a threshold
of 140 mg/dL (7.7 mmol/L) at 1 hour or 120 mg/dL at 2 hours after meals.

47. • Medical management of maternal hyperglycemia in women with
pregestational diabetes – s/c INSULIN .
• Women with GDM or mild type 2 diabetes may be treated with oral
medications such as metformin or glyburide instead of insulin.
• Metformin - decreases hepatic glucose production, decreasing intestinal
absorption of glucose, and by improving insulin sensitivity in peripheral
tissues. Metformin has a low risk of producing hypo- glycemia.
• Glyburide acts on the pancreas to promote and increase insulin secretion

48. TIMING OF DELIVERY
• For pregestational diabetics and gestational diabetics requiring medication
management, timed early delivery has been considered in an attempt to reduce
perinatal morbidity and mortality.

49. TAKE HOME POINTS
• The incidence of diabetes in pregnancy is steadily rising, likely in parallel with the
rising incidence of obesity among women of reproductive age.
•
• Women with diabetes are at increased risk for fetal complications (such as
congenital malformations, fetal growth abnormalities, and stillbirth) and
perinatal/neonatal complications
• Good maternal glycemic control achieved preconception and maintained
throughout pregnancy is key to optimizing fetal and neonatal outcomes.
• Breastfeeding should be strongly encouraged and supported as it may reduce
some of the possible adverse effects of intrauterine programming in the context
of maternal diabetes.