1. Infant of Diabetic Mother 9/4/2005

2. Infant of diabetic mother • Introduction • Pathophysiology • Presentation & clinical manifestations • Prognosis • treatment

3. IDM • Diabetic mothers have high risk pregnancies • Fetal mortality rate is higher at all gestational ages • Fetal loss throughout pregnancy is associated with uncontrolled diabetes in the mother • LGA & IUGR

4. Pathophysiology • Maternal hyperglycemia leads to fetal hyperglycemia. • Hyperinsulinemia • Pathological findings: • Hypertrophy & hyperplasia of pancreatic cells • Increase wt of placenta & infant organs` • Extramedullary hematopoeisis • Still birth • Hypoglycemia after birth

5. Pathophysiology • Hyperinsulinemia in both GDM & IDDM • Response to glucose & arginine • Hyperinsulinism & diminished catecholamine respnonse • Cortisole & hGH are normal • Poor control in the periconceptual period leads to congenital anomalies

6. Clinical manifestations • Large & plump • Puffy & plethoric • May be normal, or have low birth wt. • Hypoglycemia : 25-50% of IDM , 15-25% of IGDM. • The lowest glucose level : 1-3hrs , spontaneous recovery 4-6% • Jumpy , hyperexcitable or lethargic , hypotonic.

7. Hypocalcemia • Hypomagnesemia • Tachypnea in the first 2 days: • Hypoglycemia • Hypothermia • Polycythemia • Cardiac failure • TTN • Cerebral edema • Higher incidence of RDS

8. Crdiomegaly 30% • Heart failure 5-10% • Asymmetric septal hypertrophy: inotropic agents are contraindicated • Birth trauma • Immature neurologic development • Delay in ossification centers • Hyperbilirubenemia • Renal vein thrombosis

9. Incidence of cngenital anomalies is increased 3 fold : • Cardiac anomalies • Lumbosacral agenesis • Neural tube defects • Hydronephrosis , renal agenesis • Duedenal, anorectal atresia • Situs inversus • Holoprosencephaly • Small left colon syndrome

10. prognosis • Incidence of diabetes mellitus is increased in IDM • Physical development is normal • Obesity • Impaaired intellectual development???? • Hypoglycemia • Maternal ketonuria

11. Treatment • Frequent prenatal evaluation of mothers at risk. • Fetal evaluation • Delivery planning • Periconceptual glucose control,control during labor • GDM:glyburide vs. insulin

12. Treatment • Close observation : regardless of birth weight

13. Hypoglycemia • Asymptomatic:Blood glucose levels : within 1st hr, then hrly for 6-8 hrs, if normoglycemic start feeding ASAP ( oral or NG) • If feeding unsuccessful: IV glucose 4-8 mg/kg/min

14. Hypoglycemia should be treated whether symptomatic or not: feeding &/or IV glucose. • Hypertonic glucose should be avoided. • Symptomatic( convulsions, tremors, cyanosis,apneic spells,eye rolling , difficult feeding sweating, hypothermia, lethargy…) • IV bolus of 200mg/kg ( 2cc/kg of DW 10%), if seizures 4mg/kg to be given. • IV infusion at rate of 8mg/kg/min

15. If inadequate concentration can go up to 20% . • Hydrocortisone: 5mg/kg/day , BID, IM • Crystalline glucagon IM or SQ • If still inadequate : diazoxide • Octreotide • Measure glucose hrly then Q 4-6 hrs • Never abruptly stop IV glucose infusion.: reactive hypoglycemia

16. Hypoglycemia usually resolves within 24 hrs • Persistent hypoglycemia : persistent hyperinsulinemia • If more than 7 days consider other causes:

17. Hypocalcemia • Found In 22% of IDM • The nadir 24-72 hrs • Total serum calcium below 7 mg/dl • In well babies resolves without treatment • Treatment may be necessery : unable to feed , symptomatic , has a coexisting illness.

18. Thank you !